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No  one  ivho  has  written  a  book  has  of  himself 
become  what  he  is;  everyone  stands  on  the 
shoulders  of  his  predecessors;  all  that  was 
produced  before  his  time  has  helped  to  form 
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— Freytag 


PRINCIPLES  AND  METHODS 


ORTHODONTICS 


AN    INTRODUCTORY   STUDY   OF   THE    ART 

FOR   STUDENTS  AND   PRACTITIONERS 

OF   DENTISTRY 


BY 

B.  E.  LISCHER,  D.M.D. 

PROFESSOR  OF  ORTHODONTICS,  WASHINGTON  UNIVERSITY  DENTAL  SCHOOL;    MEMBER 

OF  THE   AMERICAN   SOCIETY   OP  ORTHODONTISTS;  AUTHOR  OF 

"  ELEMENTS   OF  ORTHODONTIA,"  ETC. 


ILLUSTRATED   WITH    248    ENGRAVINGS 


LEA   &    FEBIGER 

PHILADELPHIA    AND    NEW    YORK 


Entered  according  to  the  Act  of  Congress,  in  the  year  1912,  by 

LEA    &    FEBIGER 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE 


The  introductory  study  of  the  art  here  offered  to  students 
and  practitioners  of  dentistry  was  begun  with  the  intention 
of  furnishing  a  plain  statement  of  present-day  tendencies. 
But  the  author  soon  found  it  impossible  to  proceed  with- 
out Adopting  a  point  of  view  which  implied  a  more  or 
less  "independent  reconstruction  of  the  existing  situation." 
This  necessitated  the  omission  of  details  which,  historically 
at  least,  are  of  great  significance. 

Many  of  the  fundamental  facts  of  the  science  (which 
have  been  appropriated  from  such  cognate  studies  as 
anatomy)  have  likewise  been  omitted,  on  the  assumption 
that  every  student  has  had  adequate  previous  training  in 
them.  Similarly  was  it  deemed  advisable  to  eliminate  the 
description  of  such  technical  phases  as  plaster  model  con- 
struction, details  of  soldering,  etc.,  with  which  every  dentist 
is  conversant  and  which  rightfully  belong  to  the  laboratory 
course.  Nor  has  there  been  any  attempt  made  to  present 
the  more  recent  discussions  and  debates  with  which  our 
journal  literature  abounds.  The  dental  school  course  does 
not  permit  of,  nor  does  the  beginner  require,  such  minute 
exposition  of  the  subject.  In  brief,  the  author  presents  the 
volume  in  that  limited  sense  which  its  subtitle  implies,  and 
with  the  hope  that  its  pages  will  prove  ])oth  interesting  and 
instructive. 


vi  PREFACE 

The  author  desires  to  express  his  thanks  to  the  pubUshers 
for  the  many  courtesies  shown  him  during  the  preparation 
of  the  volume;  to  other  publishers  and  authors  for  the  use 
of  several  cuts;  and  to  his  friend  and  collaborator,  Dr. 
M.  N.  Federspiel,  of  Milwaukee,  for  his  valuable  counsel. 

B.  E.  L. 

Washington  TJnivebsity  Dental  School. 
St.  Louis.  1912. 


CONTENTS 


INTRODUCTION 

CHAPTER  I 

THE    STUDY    OF    ORTHODONTICS 

Definition  and  Scope  of  Orthodontics 17 

The  Literature  of  Orthodontics 20 

The  Practice  of  Orthodontics 23 

The  Technique  of  Orthodontics 26 


PART   I 
PRINCIPLES  OF  TREATMENT 

CHAPTER  II 

PREPARING    THE    MOUTH    FOR    TREATMENT 

Examination  of  the  Patient 32 

The  ReUef  of  Pain 35 

Cleansing  the  Teeth 36 

Instruction  in  Oral  Hygiene 37 

Treatment  of  Caries 38 

The  Extraction  of  Teeth 40 

CHAPTER  III 

KEEPING  RECORDS  OF  THE  TREATMENT 

Written  Records 43 

Plaster  Models 46 

Photographs 49 

Radiographs 50 


VUl 


CONTENTS 


CHAPTER  IV 

THE    ETIOLOGY   OF   MALOCCLUSION 


Definition 

52 

Classification  of  the  Factors 

52 

Intrinsic  Factors 

55 

Extrinsic  Factors      .            ... 

66 

Unknown  Factors 

77 

CHAPTER  V 

THE    DIAGNOSIS   OF   MALOCCLUSION 

First  Principles 80 

Definition 83 

General  Outline  of  the  Anomalies  of  Dentition 84 

Differentiation  of  the  Various  Forms 85 

Summary 96 

CHAPTER  VI 

FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

Normal  Variations  of  the  Head  Form 97 

Abnormal  Variations  of  the  Profile 108 

Orthodontic  Conceptions  and  Ideals 118 

Diagnostic  Methods 126 


CHAPTER  VII 

THE    PROGNOSIS   OF   MALOCCLUSION 

Definition 130 

General  Considerations 131 

Special  Considerations 133 

Clinical  Summary 138 

CHAPTER  VIII 

THE   EVOLUTION   OF   METHODS 

Methods  of  the  Past 144 

Rise  of  the  Systems 148 

Lines  of  Advance 151 

Details  of  Design 152 


CONTENTS  JX 
CHAPTER  IX 

PRINCIPAL   ELEMENTS   OF   MODERN   METHODS 

The  Plain  Band 154 

The  Anchor  Band 156 

The  AHgnment  Wire 159 

Ligatures  and  Elastics 162 

Miscellaneous  Accessories 163 

CHAPTER  X 

PRINCIPLES   OF   APPLICATION 

Forms  of  Anchorage 164 

Stationary  Anchorage 165 

Reciprocal  Anchorage 166 

Intramaxillary  xlnchorage 167 

Intermaxillary  Anchorage 168 

Extramaxillary  Anchorage        . 170 

CHAPTER  XI 

DETAILS   OF   APPLICATION 

The  Anchor  Band 173 

The  Plain  Band 175 

The  Alignment  Wire 176 

Ligatures  and  Elastics 181 

CHAPTER  XII 

PRINCIPLES   OF   RETENTION 

Tissue  Changes  Caused  by  Tooth  Movement 183 

Definition  of  Retention 184 

Maintenance  of  Tooth  Position 18G 

Maintenance  of  Arch  Form 187 

Maintenance  of  Arch  Relation 189 


X  CONTENTS 

PART    II 
METHODS  OF  TREATMENT 

CHAPTER  XIII 

TREATMENT   OF   MALPOSITION   OF   THE   TEETH 

Labioversion  and  Buccoversion 191 

Linguoversion 195 

Distoversion 198 

Mesioversion 201 

CHAPTER  XIV 

TREATMENT   OP   MALPOSITION    (CONTINUED) 

Torsoversion       . 203 

Infraversion 208 

Supraversion 210 

Perversion  and  Transversion 212 

CHAPTER  XV 

TREATMENT   OF   NEUTROCLUSION 

Simple  Neutroclusion 213 

Complex  Neutroclusion 226 

CHAPTER  XVI 

TREATMENT   OF   DISTOCLUSION 

Bilateral  Distoclusion 245 

Unilateral  Distoclusion 265 

CHAPTER  XVII 

TREATMENT   OF   MESIOCLUSION 

Bilateral  Mesioclusion 272 

Unilateral  Mesioclusion 281 

CHAPTER  XVIII 

TREATMENT   OF   MALFORMATIONS   OF   THE   JAWS    .        .       284 


ORTHODONTICS 


INTEODUCTION 


CHAPTER    I 

THE  STUDY  OF  ORTHODONTICS 

DEFINITION  AND  SCOPE  OF  ORTHODONTICS 

Orthodontics  is  a  term  proposed  by  Sir  James  Murray, 
the  eminent  philologist,  to  cover  that  branch  of  dentistry 
which  deals  with  the  principles  and  practices  involved  in  the 
prevention  and  correction  of  malocclusion  of  the  teeth,  and  such 
other  malformations  and  abnormalities  as  may  be  associated 
therewith.  Dr.  Frederick  B.  Noyes^  defines  it  as  "the 
study  of  the  relation  of  the  teeth  to  the  development  of  the 
face,  and  the  correction  of  arrested  and  perverted  develop- 
ment." It  is  of  dental  origin,  having  been  reared  by  dental 
practitioners,  and  is  a  crowning  achievement  of  the  dental 
progress  of  the  last  generation.  The  terms  Orthodontia, 
Odontorthosia,  Dental  Orthopedics,  and  Dental  Orthomorphia, 
which  are  less  acceptable  from  a  linguistic  standpoint,  are 

1  The  Dental  Cosmos,  January,  1911. 


18  THE  STUDY  OF  ORTHODONTICS 

also  used.  Like  general  dentistry,  orthodontics  is  a  part 
of  the -vast  field  of  medicine,  and  when  we  recall  "that  all 
sciences  which  deal  with  life,  with  force,  and  with  chemical 
composition"  entej'  into  the  study  of  medicine,  we  may 
fairly  comprehend  the  breadth  of  its  base. 

Orthodontics  as  a  Science. — As  a  science  it  is  closely 
related  to  many  of  the  medical  sciences,  the  basis  of  which 
is  biology,  the  science  of  life.  "Life,  that  strange,  unknown 
something  which  flies  through  the  viewless  air,  flashes  through 
the  ocean's  depths,  blushes  in  the  petals  of  a  rose,  and  mani- 
fests itself  in  thousands  of  marvellous  forms — can  science 
grasp,  define,  or  explain  it?"  In  the  present  stage  of  our 
knowledge  probably  not  completely;  but  it  teaches  us  that 
all  vital  processes,  including  man  and  all  his  characteristics, 
as  well  as  those  of  all  other  species,  are  the  result  of  the 
interaction  of  certain  law^s.  To  define  these  laws,  to  test 
them  in  the  crucible  of  observation  and  experiment,  and 
then  to  express  them  in  terms  of  human  experience — this  is 
the  mission  of  science. 

Now,  the  treatment  of  dental  anomalies  involves  us  in 
countless  difficulties,  hence  "we  seek  truth  not  merely  for 
the  pleasure  of  knowing,  but  in  order  to  have  a  lamp  for 
our  feet.  We  toil  at  building  sound  theory  in  order  that  we 
may  know  what  to  do  and  what  to  avoid."  Thus  the  jDrocess 
of  dentition,  its  mechanism,  causes,  and  various  develop- 
mental stages,  as  exemplified  by  comparative  studies,  is  not 
without  meaning,  but  furnishes  a  field  of  compelling  interest 
to  every  intelligent  dentist.  It  is  further  apparent  that  a 
comprehensive  knowledge  of  the  development  of  the  jaws,  and 
of  the  nasal  passages  and  their  accessory  sinuses  (which  are 
so  intimately  related  to  them),  is  also  desirable.  A  frequent 
attribute  of  malocclusion  of  the  teeth  is  a  marked  inharmo7iy 


DEFINITION  AND  SCOPE  OF  ORTHODONTICS       19 

of  the  facial  lines.  The  true  basis  of  a  differential  classi- 
fication of  such  deformities  is  a  wide  familiarity  with  ethnic 
variations  of  the  head  form.  A  valuable  aid  in  the  study  of 
the  various  forms  of  malocclusion  of  the  teeth  is  an  inquiry 
into  the  classification  of  all  anomalies,  the  relations  of 
anomalies  to  disease,  and  the  foundations  of  teratology  in 
general.  Again,  a  consideration  of  the  causative  factors 
opens  a  large  field  of  inquiry  to  the  student  of  orthodontics, 
owing  to  their  intimate  connection  with  the  theories  of  inheri- 
tance, the  transmission  of  acquired  characters,  and  other  allied 
Darwinian  factors  and  biological  problems.  Another  essen- 
tial to  a  scientific  comprehension  of  treatment  is  a  careful 
consideration  of  the  tissues  of  attachment,  i.  e.,  the  alveolus 
and  pericementum,  and  the  changes  they  undergo  during  and 
after  tooth  movement. 

All  these  are  questions  for  the  scientific  orthodontist  to 
investigate,  and,  if  possible,  to  explain;  he  must  search  for 
the  laws  underlying  them,  tell  why  they  are  so,  and  indi- 
cate the  place  they  occupy  in  the  scheme  of  things.  Finally, 
to  render  our  studies  less  difficult,  and  to  perfect  the  nomen- 
clature of  orthodontics,  we  must  strive  to  develop  a  greater 
accuracy  of  expression  and  uniformity  of  usage  of  the  terms 
we  employ  in  our  speech. 

The  practice  of  medicine,  in  any  of  its  branches,  consti- 
tutes a  remedial  art;  for  art  consists  in  doing,  in  the  appli- 
cation of  knowledge.  "The  subject  matter  of  art  is  life, 
life  as  actually  is;  but  the  function  of  art  is  to  make  life 
better.  Operations  become  arts  when  their  purpose  is 
conscious  and  their  method  teachable." 

Orthodontics  as  an  Art. — As  an  art,  orthodontics  is  con- 
cerned with  the  principles  and  methods  of  treatment;  what 
these  are  the  present  \-olume  briefly  tries  to  show. 


20  ^       THE  STUDY  OF  ORTHODONTICS 


THE  LITERATURE  OF  ORTHODONTICS 

All  endeavors  to  find  adequate  treatment  of  our  subject 
in  the  earliest  historic  times  have  been  fruitless.  Thus, 
Farrar^  writes  of  a  review  b}^  Litch  (1839),  based  upon  some 
four  hundred  works  on  dentistry,  and  all  they  contained 
relating  to  the  subject  could  have  been  gathered  in  one 
volume  of  moderate  size.  And  though  Celsus  (a.d.  30)  is 
said  to  have  recommended  finger  pressure  for  the  correction 
of  malposition  of  the  teeth,  we  can  find  no  attempts  at 
systematic  treatment  of  the  subject  until  the  publication 
of  Fauchard's^  admirable  book.  The  work  of  this  eminent 
pioneer  was  not  exclusively  devoted  to  orthodontics,  but  he 
regarded  the  subject  of  sufficient  importance  to  describe 
various  methods  of  treatment  and  to  dwell  upon  the  etiology 
of  malocclusion. 

The  earliest  recorded  special  work  is  that  by  the  German 
dentist,  F.  C.  Kniesel,  entitled  Der  Schiefstand  der  Zdhne, 
in  the  German  and  French  languages,  and  published  in 
Berlin  in  1836.  During  the  interval  embraced  by  the  dates 
of  publication  of  these  two  books  the  field  of  orthodontics 
was  variously  treated  by  dental  authors,  notable  among 
whom  were  Bunon  (1742),  Bourdet  (1757),  Berdmore  (1770), 
Fox  (1803),  Delabarre  (1806),  and  Catalan  (1808).  The 
joint  treatment  of  its  subject  matter  with  other  phases  of 
dentistry  continued  the  prevailing  custom  for  many  decades, 
in  fact,  up  to  the  present.  Among  the  more  prominent 
dental  texts  that  continued  thus  to  treat  it  are  the  following : 
Handbuch  der  Zahnheilkunde,  Linderer,  1842;  Systematisches 

'  Irregularities  of  the  Teeth,  vol.  i,  p.  12. 
2  Le  chirurgien  dentiste,  Paris,  1728. 


THE  LITERATURE  OF  ORTHODONTICS  21 

Handbuch  der  Zahnheilkunde,  Carabelli,  1844;  American 
System  of  Dentistry,  vol.  ii,  Litch — Guilford,  1887;  American 
Text-book  of  Operatire  Dentistry,  Kirk — Angle  and  Case, 
fourth  edition,  1911;  Dental  Surgery,  Tomes,  fifth  edition, 
1906;  A  Text-book  of  Operative  Dentistry,  Johnson — Pullen, 
1908. 

In  1880  Dr.  Norman  Kingsley,  of  New  York,  published 
the  first  American  text  on  orthodontics,  entitled  Oral 
Deformities.  The  volume  embraced  several  chapters  on 
malocclusion  of  the  teeth,  their  etiology,  diagnosis,  and 
treatment;  besides  a  consideration  of  cleft  palates  and 
fractures  of  the  maxillae  and  their  treatment. 

In  1888  appeared  the  two-volume  work  of  Dr.  J.  N, 
Farrar,  of  New  York,  entitled  Irregularities  of  the  Teeth. 
These  volumes  are  a  veritable  mine  of  orthodontic  data, 
and  cannot  be  otherwise  regarded  than  epoch-making.^ 
This  eminent  pathfinder  of  the  art  was  the  founder  not 
only  of  the  "systems,"  but  of  present-day  methods  of 
treatment. 

In  the  meantime,  general  dentistry  was  making  rapid 
progress;  every  department  was  being  influenced  by  the 
vast  extension  of  human  knowledge  during  the  last  half  of 
the  nineteenth  century.  The  growth  of  dental  literature 
was  now  to  proceed,  and  orthodontics  claimed  many  enthusi- 
astic workers.  It  will  be  convenient  to  arrange  all  recent 
writers  according  to  nationality,  and  by  continuing  our 
discussion  of  American  authors  we  come  to  the  work  of 
Talbot,  Irregularities  of  the  Teeth,  fourth  edition,  1901.  The 
book  is  said  by  its  author  to  be  "  an  outgrowth  of  researches 
which  tended  to  oppose  the  too  prevalent  theory  that  irregu- 
larities of  the  teeth  and  jaws  were  the  result  of  local,  not 

1  Pfaff,  Lehrbuch  der  Orthodontie,  2d  ed.,  p.  373. 


22  THE  STUDY  OF  ORTHODONTICS 

constitutional  causes."  Most  of  us  believe  this  to  be 
extreme  teaching;  but  it  should  be  read,  owing  to  its  treat- 
ment of  the  subject  of  degeneracy.  Orthodontia,  by  S.  H. 
Guilford,  fourth  edition,  1905,  has  been  a  favorite  intro- 
duction for  many  years  Malocclusion  of  the  Teeth,  by  E.  H. 
Angle,  seventh  edition,  1907,  is  an  exposition  of  the  Angle 
System,  and,  like  other  works  published  in  the  last  decade, 
open  to  criticism  because  of  its  exclusive  originality  of 
presentation.  The  works  of  Knapp,  Orthodontia  Practically 
Treated,  1904;  of  Jackson,  Orthodontia  and  Orthopedia  of 
the  Face,  1904;  and  of  Case,  Dental  Orthopedia,  1908,  are 
treatises  of  the  same  group,  each  volume  being  a  presentation 
of  the  author's  methods.  These  remarks,  however,  are  not 
intended  as  an  index  of  the  relative  value  of  these  works, 
since  they  contain  much  that  the  student  cannot  afford 
to  ignore.  The  work  by  MacDowell,  Orthodontia,  1901, 
concludes  the  list  of  American  authors. 

The  foreign  literature,  though  not  so  large,  is  a  creditable 
showing  for  a  speci^alty  as  young  as  orthodontics.  In 
England  there  is  the  excellent  little  volume  of  essays  by 
Wallace,  entitled  Irregularities  of  the  Teeth,  1904;  and  the 
more  pretentious  text  by  Colyer,  of  the  same  title,  published 
in  1900. 

In  Germany  there  is  the  work  of  Walkhoff,  Die  Unregel- 
mdssigkeiten  in  den  Zahnstellungen  und  Ihre  Behandlung 
(1891),  and  the  texts  by  Jung  (1906),  Pfaff  (second  edition, 
1908),  Herbst  (1910),  and  the  excellent  little  manual  by 
Korbitz  (second  edition,  1911). 

In  France  the  art  is  represented  by  the  works  of  Gaillard 
(1909),  Martinier  (1903),  and  Donogier  (1895).  Spanish 
dentists  have  recently  (1909)  welcomed  a  work  by  Subirana, 
entitled  Anomalies  de  la  Oclusion  dentaria  y  Ortodoncia. 


THE  PRACTICE  OF  ORTHODONTICS  23 

Controversial  writings,  the  reports  of  cases,  and  modi- 
fications of  technical  details  (whose  proper  place  is  in  the 
journals)  have  been  liberally  })resented  b}'  dental  maga- 
zines, many  of  them  conducting  departments  of  orthodon- 
tics.^ In  Germany  a  monthly  journal  exclusively  devoted 
to  the  art  has  recently  (1907)  been  established,  entitled 
Zeitschrift  fiir  Zahndrztliche  Orthoyddie . 

Much  of  the  recent  periodical  literature  represents  the 
proceedings  of  societies  and  scientific  associations.  In  the 
general  bodies,  such  as  State,  national,  and  international 
societies,  sections  are  frequently  organized  for  the  more 
deliberate  consideration  of  orthodontic  problems.  Among 
the  societies  exclusively  devoted  to  orthodontics,  mention 
may  be  made  of  the  American  Society  of  Orthodontists, 
the  British  Society  for  the  Study  of  Orthodontics,  and  the 
Deutschen  Gesellschaft  fiir  Orthodontic,  etc. 

Thus  the  art,  though  hardly  out  of  its  teens,  has,  never- 
theless, an  extensive  library;  and  at  its  present  rate  of  growth 
bids  fair  to  equal  in  content,  as  well  as  in  volume,  the  liter- 
ature of  other  branches  of  dentistry.  The  recent  proposal 
of  A.  D.  Black^  that  the  profession  adopt  the  Dewey  decimal 
system  of  classification  for  dental  literature  will  render 
available  the  countless  articles  in  our  magazines,  covering 
every  phase  of  the  sub  ect. 


THE  PRACTICE  OF  ORTHODONTICS 

Recent  advances  in  the  methodology  of  the  art  and  the 
consequent  extension  of  its  boundary  lines  have  abinidanth' 

1  Items  of  Interest,  New  York. 

2  Proc.  Inst.  Dent.  Pedagogics,  Sixteenth  Annual  Report. 


24  ^       THE  STUDY  OF  ORTHODONTICS 

justified  its  separation  from  general  practice  in  all  com- 
munities capable  of  supporting  the  specialist.  The  many 
advantages  of  specialization  are  so  well  known  that  a 
restatement  of  them  here  is  deemed  unnecessary.  Ortho- 
dontic services  by  their  very  nature  readily  constitute  a 
special  and  ample  field.  Hence  the  point  we  wish  here 
to  emphasize  is  the  dependence  and  independence  of  the 
two  fields,  their  limitations  and  relations,  and  to  indicate 
the  course  one  ought  to  follow  if  one  contemplates  the 
practice  of  orthodontics.  This  theme  has  been  the  subject 
for  numerous  articles  in  the  journals,  though  rarely  has  it 
been  so  ably  presented  as  in  the  paper  by  Dr.  Ottolengui, 
entitled  "The  Sphere  of  the  Dentist  in  the  Field  of  Ortho- 
dontia," from  which  we  quote  the  following:^ 

"  I  respectfully  submit  it  is  my  view  that  the  best  ortho- 
dontists of  the  future,  as  in  the  past,  must  be  forthcoming 
from  the  ranks  of  such  men  as  begin  in  the  regular  practice 
of  dentistry,  and  gradually  choose  to  practise  orthodontia 
exclusively  from  a  pure  love  of  the  work,  and  especially 
because  of  their  inherent  love  for,  and  patience  with, 
children. 

"If  this  be  true,  it  follows  as  a  logical  sequence  that  the 
dentist  has  the  moral  as  well  as  the  legal  right  to  practise 
orthodontia;  but  he  should  have  no  legal  right,  as  surely  he 
has  no  moral  right,  to  undertake  orthodontic  work  without 
a  full  and  competent  knowledge  of  the  present  requirements 
and  technique.  Any  physician  may  treat  the  eye,  the  nose, 
the  throat,  or  do  any  operation  in  surgery  if  he  has  the 
ability  to  do  so  successfully;  but  he  may  be  mulcted  in 
heavy  damages  if  he  attempt  such  work  and  fail,  because  of 

I  Items  of  Interest,  November,  1909,  p.  819. 


THE  PRACTICE  OF  ORTHODONTICS  25 

lack  of  proper  training  or  skill.     The  medical  degree  is  no 
protection  to  the  malpractitioner. 

"It  is  the  same  in  dentistry.  Any  dentist  may  undertake 
the  treatment  of  malocclusion,  but  he  is  guilty  of  malprac- 
tice in  some  degree  if  he  does  not  first  acquire  the  needed 
training  and  knowledge. 

"The  sphere  of  the  dentist  in  orthodontia  is,  therefore,  to 
be  considered  from  a  dual  aspect:  (1)  The  general  prac- 
titioner who  elects  to  treat  malocclusion  occasionally,  and 
(2)  the  dentist  who  decides  to  refer  all  such  cases  to  the 
specialist.  The  first  man  should  have  exactly  the  same 
knowledge  as  the  specialist  himself.  For,  if  the  dentist  treat 
but  one  case  a  year,  he  is  morally  bound  to  know  how,  or 
else  refer  the  patient  elsewhere. 

"On  the  other  hand,  the  general  practitioner  who  decides 
not  to  treat  malocclusion,  but  elects  to  recommend  a  special- 
ist, should  at  least  inform  himself  sufficiently  of  the  art  to  be 
a  competent  judge  of  the  success  or  failure  of  the  specialist 
into  whose  hands  he  takes  the  responsibility  of  placing  the 
management  of  the  teeth  and  jaws  of  a  growing  child.  For, 
it  should  be  remembered,  there  are  degrees  of  excellence  in  all 
crafts,  and  the  mere  fact  that  a  man  may  announce  that  he 
has  decided  to  'restrict  his  practice  to  orthodontia'  does  not 
prove  that  he  is  competent." 

As  an  additional  word  of  caution,  it  is  well  to  state  that 
no  one  should  attempt  the  exclusive  practice  of  orthodontics 
without  adequate  preliminary  training  in  general  dentistry, 
because  a  liberal  knowledge  in  the  treatment  of  the  two 
main  groups  of  oral  diseases  {i.  e.,  caries  and  lesions  of  the 
pericementum,  which  can  only  be  acquired  in  general  prac- 
tice) is  absolutely  indispensable.  It  is  imperative  that  we 
learn  by  experience  what  it  means  to  keep  a  mouth  well. 


26  THE  STUDY  OF  ORTHODONTICS 

Finally,  when  combined  with  general  dentistry  (a  neces- 
sity in  all  outlying  districts  and  rural  communities)  it  will 
be  necessary  to  so  systematize  the  office  routine  that  a 
definite  number  of  hours  be  exclusively  devoted  to  its  prac- 
tice. This  should  be  regarded  as  a  pleasant  duty  by  all 
conscientious  dentists;  for  it  has  been  estimated  that  fully 
50  per  cent,  of  the  children  in  every  community  are  afflicted 
with  some  form  of  malocclusion  of  the  teeth,  which,  in  the 
aggregate,  means  a  vast  army  of  countless  thousands  upon 
whom,  for  obvious  reasons,  the  specialist  can  never  smile. 
And  last,  but  not  least,  the  mastery  of  orthodontics  implies 
postgraduate  study,  which  the  dental  hospitals  of  our 
larger  universities  should  liberally  provide.  Such  depart- 
ments are  worthy  of  the  most  liberal  endowments,  and  it 
need  hardly  be  emphasized  that  they  should  be  open  to 
graduate  students  the  year  around. 


THE  TECHNIQUE  OF  ORTHODONTICS 

Many  of  the  earlier  works  on  general  dentistry  contained 
chapters  on  "Irregularities"  and  "Regulation,"  probably 
because  the  correction  of  malocclusion  has  always  been 
regarded  as  a  function  of  the  dentist.  A  noteworthy  char- 
acteristic of  these  texts  was  the  prominence  given  to  the 
technical  phases  of  the  art,  the  details  of  appliance  con- 
struction being  constantly  kept  in  the  foreground.  The 
treatment  of  malocclusion  being  a  mechanical  process,  in 
which  technical  methods  play  an  exceedingly  important 
part,  it  seems  quite  natural  that  the  technique  should  have 
been  regarded  as  an  important  division.  Indeed,  it  is  still 
so  regarded;  but  the  dawn  of  another  era  is  upon  us,  the 


THE  TECHNIQUE  OF  ORTHODONTICS  27 

day  of  "home-made"  appliances  is  rapidly  approaching  its 
twihght,  and  an  appreciation  of  greater  possibiKties  is 
directing  our  attention  and  energy  to  other  problems.  The 
mechanisms  of  former  days  were  usually  manufactured  by 
the  operator,  which  consumed  a  great  deal  of  his  time,  and 
so  magnified  the  details  of  construction  that  the  principles 
utilized  were  frequently  lost  sight  of. 

The  following  prophecy  from  the  pen  of  Dr.  J.  N.  Farrar^ 
appeared  in  1878:  "Although  the  simplification  of  regula- 
tion has  been  a  great  desideratum  for  many  years,  it  has  for 
some  time  been  evident  to  me  (though  by.  most  people 
thought  to  be  impracticable)  that  the  time  will  come  when 
the  regulation  process  and  the  necessary  apparatus  will  be  so 
systematized  and  simplified  that  the  latter  will  actually  be 
kept  in  stock,  in  parts  and  in  wholes,  at  dental  depots,  in 
readiness  for  the  dental  profession  at  large,  so  that  it  may  be 
ordered  by  catalogue  numbers  to  suit  the  needs  of  the  case;  so 
that  by  a  few  moments'  work  at  the  blowpipe  in  the  labora- 
tory the  dentist  may  be  able,  by  uniting  the  parts,  to  pro- 
duce any  apparatus,  of  any  size  desired,  at  minimum  cost  of 
time  and  money." 

That  prediction  has  been  fulfilled;  orthodontics  has 
passed  through  its  elementary  stages,  and  finally  reached 
as  high  a  degree  of  development  as  other  departments  of 
dentistry.  There  was  a  time  when  the  operator  made  his 
pluggers  and  other  instruments,  and  the  prosthodontist  his 
plate  gold  and  solders;  similarly  was  it  considered  an  ortho- 
dontist's duty  to  invent  and  construct  the  appliances  for  a 
case  in  hand.  But  after  years  of  ceaseless  toil,  "of  immeas- 
urable devotion  of  energy  and  time  and  genius"  to  a  most 

1  The  Dental  Cosmos,  January,  1878. 


28  THE  STUDY  OF  ORTHODONTICS 

worthy  art,  certain  facts  of  experience  have  finally  been 
systematized.  Indeed,  the  whole  spirit  of  effort  of  the  last 
decade  has  been  a  reaction  against  former  methods,  and 
has  been  characterized  by  a  demand  for  a  new  arrange- 
ment, for  some  settled  principles  in  the  art.  A  mere  heaping 
together  of  disconnected,  confusing  methods  has  long  since 
ceased  to  satisfy  all  serious  students.  Thus,  there  comes  the 
concession  from  all  sides  that  appliances  are  but  the  means 
to  an  end — the  remedies,  as  it  were — with  which  the  operator 
should  so  familiarize  himself  as  to  master  their  use  and 
manner  of  application,  not  their  manufacture. 

"Systems." — From  the  standpoint  of  this  new  and 
higher  perspective,  and  in  response  to  the  urgent  demands 
of  progress,  several  so-called  "systems"  have  been  offered 
to  the  profession,  every  one  of  which  embraces  much  that 
is  good.  But  a  system,  at  best,  is  but  a  compilation  of 
certain  definite  principles,  elements  of  design,  and  methods  of 
treatment,  and  these  rarely  are  the  product  of  a  single  mind. 
It  usually  represents  the  results  of  the  separate  efforts  of 
several  individuals,  and  may  even  be  compiled  for  private 
gain.  On  the  other  hand,  a  system  may  have  a  higher  motive, 
and  tersely  emphasize  the  advantages  of  simplicity  of  tech- 
nique, or  the  achievements  of  unusual  skill.  Doubtless  their 
influence  upon  our  technique  has  been  salutary,  though  our 
resultant  methods  continue  to  impose  definite  technical 
attainments.  Hence,  laboratory  courses  in  orthodontics, 
similar  to  those  of  operative  and  prosthetic  dentistry,  of 
chemistry  and  bacteriology,  have  become  permanent  fixtures 
in  the  dental  curriculum.^  The  student  frequently  under- 
estimates the  importance  of  this  phase  of  the  subject,  and 

1  Lischer,  Elements  of  Orthodontia,  St.  Louis,  1909. 


THE  TECHNIQUE  OF  ORTHODONTICS  29 

defers  its  accomplishments  until  launched  in  private  prac- 
tice; when  the  demands  of  a  growing  patronage  and  the 
unavoidable  difficulties  of  treatment  militate  against  the 
acquirement  of  that  special  dexteritj^  so  essential  to  success. 
Moreover,  it  is  immaterial  which  method  of  treatment  an 
operator  will  ultimately  adopt — whether  it  be  a  system  as 
such,  or  a  combination  of  several — the  technical  training 
enjoined  in  either  case  will  always  be  considerable.  Thus, 
the  application  of  appliances  for  treatment,  the  accepted 
methods  of  keeping  records,  and  the  construction  of  reten- 
tion appliances  demand  a  very  high  order  of  skill;  and  one 
arrives  at  skill  only  by  patient  labor,  by  the  practice  of  an 
exacting  discipline.  Let  every  student  of  orthodontics 
remember,  therefore,  that  the  laboratory  course  is  always 
designed  for  a  definite  purpose,  that  it  fits  well  into  the 
plan  of  things,  and  that  there  is  no  short  cut  across  the 
plane  of  accomplishment. 


PART  I 
PRINCIPLES  OF  TREATMENT 


CHAPTER    II 
PREPARING  THE  MOUTH  FOR  TREATMENT 

Surgical  cleanliness  on  the  part  of  the  operator  and  his 
equipment  is  the  first  rule  in  all  operative  procedures.  Since 
the  founding  of  bacteriology  by  Pasteur,  and  its  wonderful 
development  by  medical  scientists,  leading  to  the  discovery 
of  the  relations  of  bacteria  to  animals  in  health  and  disease, 
it  has  received  a  new  interpretation.  Were  it  not  for  the 
fact  that  its  omission  continues  the  prevailing  custom  with 
far  too  many  operators,  it  would  not  receive  mention  here. 
Indeed,  its  presentation  is  hardly  appropriate  in  a  work  on 
orthodontics. 

Following  the  reception  of  the  patient,  the  adjustment 
of  the  operating  chair  and  its  accessories,  should  come  the 
preparation  of  the  field  of  operation.  In  orthodontic  prac- 
tice this  has  a  special  significarce,  and  embraces  a  number 
of  important  preliminary  considerations.  The  aim  of  these 
several  preliminary  details  is  the  establishment  of  oral 
health — in  so  far  as  this  is  possible  prior  to  orthodontic 
treatment — and  to  facilitate  the  treatment. 


32        PREPARING  THE  MOUTH  FOB  TREATMENT 


EXAMINATION  OF  THE  PATIENT 

The  fundamental  importance  of  a  careful  examination  of 
every  individual  applying  for  treatment  need  hardly  be 
emphasized,  for  it  forms  the  very  basis  of  every  intelligent 
diagnosis.  A  cursory  consideration  of  the  general  health 
and  physical  development  of  the  patient  constitutes  the  first 
step  of  such  examination.  Should  any  doubt  regarding  it 
arise,  the  patient  (or  parent)  should  be  questioned  and  a 
record  made  of  recent  recovery  from  serious  ailment.  Such 
interrogations  frequently  prompt  parents  to  relate  the  pres- 
ence (or  removal)  of  adenoids,  and  other  conditions  etio- 
logically  connected  with  the  malocclusion.  The  attention 
of  the  operator  is  commonly  directed  toward  some  "promi- 
nent" incisor  or  cuspid,  which  he  will  for  the  present  ignore, 
and  consider  later  in  the  course  of  a  definite  routine. 

The  thorough  examination  of  the  oral  cavity  should  now 
proceed,  and  include,  besides  the  superior  pharynx,  the  nasal 
passages  and  form  of  the  nose;  the  function  of  the  Hps;  the 
facial  lines  and  expression;  the  jaws  beyond  the  immediate 
alveoli;  the  relative  immunity  or  susceptibility  to  caries; 
the  condition  of  the  gums  and  pericementa;  the  form  of 
the  palate;  the  frena  of  the  lips  and  tongue;  and  all  surfaces 
of  the  crowns  of  all  teeth.  Though  a  differential  diagnosis 
of  the  malocclusion  suggests  itself  here,  it  is  usually  best  to 
defer  the  same  until  accurate  models  have  been  constructed. 
Instruments. — The  instruments  required  for  an  examina- 
tion consist  of  a  mouth  mirror  (Fig.  1),  of  non-magnifying 
type,  with  metal  handle.  A  plain,  long-handled  exploring 
instrument,  of  a  pattern  as  shown  in  Fig.  2,  is  used  for  the 
location  and  exploration  of  carious  cavities.     The  use  of 


EXAMINATION  OF  THE  PATIENT 


33 


Fig.  1 


Fig.  2 


Mouth  mirror. 


Exploring  instiument. 


34        PREPARING  THE  MOUTH  FOR  TREATMENT 

floss  silk  in  the  interproximal  spaces  and  contact  areas  is 
also  advised.  A  tongue  depressor  of  simple  design  (Fig.  3)  is 
used  for  the  examination  of  the  superior  pharynx.  Patho- 
logical conditions  of  the  nasal  passages  which  may  stand  in 
causal  relation  to  the  malocclusion  and  require  the  services 


Fig.  3 


Fig.  4 


Tongue  depressor. 


Nasal  speculum. 


of  a  rhinologist  may  frequently  be  detected  with  a  nasal 
speculum  (Fig.  4).  A  pair  of  operating  pliers  and  some 
aseptic  absorbent  paper,  for  the  drying  of  tooth  surfaces, 
are  useful  accessories.  All  of  these  instruments  should  be 
in  readiness  upon  the  operating  table,  and  all  unnecessary 
appliances  removed.     Finally,  a  memorandum  of  all  obser- 


THE  RELIEF  OF  PAIN  35 

vations  should  be  made  upon  a  record  card  conveniently 
placed  upon  an  adjoining  table  or  desk.  The  form  of  this 
card  is  described  in  Chapter  III. 

THE  RELIEF  OF  PAIN 

The  value  of  early  treatment  for  malocclusion  is  increas- 
ingly being  appreciated,  hence  many  of  the  patients  in  an 
orthodontic  practice  are  children  in  whose  mouths  temporary 
teeth  are  still  present.  And  though  the  treatment  of  tem- 
porary teeth  is  more  widely  practised  than  formerly,  extensive 
caries,  pulp  exposure,  and  its  sequeloB  are  all  too  frequently 
met  with.  The  proper  treatment  of  such  conditions  should 
invariably  be  insisted  upon;  and  in  this  connection  let  it  be 
remembered  that  reckless  extraction  is  not  the  remedy. 
Indeed,  the  exigencies  of  many  cases  demand  their  conser- 
vation, especially  if  we  view  the  denture  as  a  whole,  and 
always  from  an  orthodontic  standpoint.  The  disastrous 
results  following  the  neglect  and  early  loss  of  temporary 
teeth  will  be  discussed  in  the  chapter  on  Etiology. 

The  temporary  teeth  are  frequently  the  seat  of  pain,  which 
many  of  the  younger  patients  fail  to  mention.  "In  every 
instance  where  there  is  suffering  the  manifest  duty  of  the 
professional  man  is  to  relieve  it  at  once  if  possible,  no  matter 
in  what  form  it  may  present  itself"  (Johnson).  The  sub- 
sequent application  and  operation  of  the  appliances  for 
tooth  movement  are  of  sufficient  annoyance  to  make  the 
above  imperative.  The  student  should  therefore  make  a 
study  of  the  causes  of  pain  and  of  all  therapeutic  aids 
and  methods  employed  for  its  alleviation.  Such  service  is 
always  appreciated,  and  goes  far  in  the  promotion  of  con- 
fidence, 


36       PREPARING  THE  MOUTH  FOR  TREATMENT 


CLEANSING  THE  TEETH 

Cleanliness  and  health  are  synonymous  terms  in  oral 
hygiene,  hence  the  next  important  preliminary  consideration 
is  a  careful  cleansing  of  the  teeth.  "Dentists  are  not  living 
up  to  the  highest  possibilities  of  their  art  when  they  fail  to 
consider  the  importance  of  maintaining  the  tissues  around 
the  teeth  in  a  state  of  health,  and  this  cannot  be  done  short 
of  a  careful  removal  of  all  extraneous  material  which  may 
be  found  adherent  to  the  teeth."  (Johnson.)  Probably  no 
two  operators  will  exactly  agree  as  to  the  instruments  to  be 
used  and  the  particular  methods  to  be  followed  in  cleaning 
the  teeth ;  but  all  must  agree  on  the  fundamental  importance 
of  the  procedure.  The  author  is  not  aware  of  any  definite 
statistics  regarding  the  matter,  but  he  feels  certain  that  only 
one  patient  in  every  hundred  presenting  themselves  prac- 
tises oral  hygiene  to  the  extent  that  orthodontic  treatment 
could  be  instituted  without  first  cleansing  the  teeth. 

But  aside  from  the  beneficial  effects  upon  the  general 
health  of  the  oral  cavity  which  every  cleaning  promotes,,  it 
must  further  be  emphasized  that  appliances  are  shortly  to 
be  adjusted.  These  are  to  be  securely  anchored  to  a  number 
of  teeth,  and  in  many  instances  remain  for  a  period  of  weeks, 
or  even  months.  Upon  their  removal,  after  tooth  movement 
has  been  accomplished,  retention  appliances  are  to  be 
inserted  for  another  prolonged  period.  Not  infrequently  the 
anchorage  of  the  latter  are  upon  the  same  teeth  previously 
utilized.  It  is  obvious,  therefore,  that  only  by  the  utmost 
cleanliness  during  the  entire  period  of  orthodontic  treatment 
can  the  health  of  the  oral  cavity  be  maintained  and  caries 
of  the  teeth  prevented. 


INSTRUCTION  IN  ORAL  HYGIENE  37 


INSTRUCTION  IN  ORAL  HYGIENE 

The  maintenance  of  physical  vigor  is  a  duty  of  every 
human  being,  and  imphes  the  practice  of  a  rigid  personal 
hygiene.  Among  its  many  requirements  few  are  of  greater 
importance  than  the  proper  care  of  the  mouth.  The  vast 
majority  of  individuals  suffering  from  dental  diseases  is 
incompetent  in  the  practice  of  an  efficient  oral  hygiene; 
hence  it  becomes  the  duty  of  the  operator  carefully  to  instruct 
patients  in  this  important  detail.  The  most  opportune  time 
for  this  instruction  is  immediately  after  the  teeth  have  been 
cleansed.  It  is  an  opportunity  the  conscientious  practitioner 
never  neglects,  and  it  should  always  be  regarded  as  an 
essential  detail  of  a  carefully  planned  routine,  because  all 
regulating  appliances  interfere  with  the  normal  functions 
of  the  mouth  and  favor  the  lodgement  of  food  particles,  thus 
promoting  caries  of  the  teeth. 

Owing  to  the  rapid  rise  of  orthodontics  as  a  specialty, 
this  discussion  brings  us  to  the  line  of  demarcation  between 
the  fields  of  the  specialist  and  general  practitioner.  An 
orthodontist  extends  his  acquaintance  and  wins  patronage 
in  any  one  of  three  legitimate  ways;  patients  are  referred  to 
him  (a)  by  the  family;  dentist,  (6)  b}^  the  family  physician, 
or  (c)  by  a  member  of  the  laity.  Of  course,  if  the  ortho- 
dontic treatment  is  instituted  by  the  family  dentist  there 
can  be  no  question  as  to  when,  or  how,  and  by  whom  these 
services  are  to  be  rendered — they  belong  to  the  general 
practitioner.  On  the  other  hand,  if  the  specialist  is  consulted, 
or  if  the  case  is  referred  to  him  by  the  dentist,  the  entire 
treatment  can  be  rendered  with  greater  dispatch  if  both 
can  agree  on  a  definite  plan,  since  all  of  these  preliminary 


38        PREPARING  THE  MOUTH  FOR  TREATMENT 

services  should  always  be  rendered  prior  to  any  orthodontic 
treatment.  But  the  specialist  must  not  underestimate 
responsibilities  during  the  period  his  services  are  being 
rendered,  and  in  all  cases  showing  a  high  degree  of  sus- 
ceptibility to  caries  he  should  encourage  the  most  liberal 
consultation  with  the  family  dentist. 

TREATMENT  OF  CARIES 

All  carious  cavities,  in  both  temporary  and  permanent 
teeth,  should  be  treated  prior  to  tooth  movement  and  in  the 

FiQ.  5 


Carious  cavities  rendered  extremely  inaccessible  by  the  malocclusion. 

best  manner  the  conditions  will  permit.  The  choice  of  a 
filling  material  is  at  times  rendered  difficult,  since  the  factor 
of  accessibility  may  enter  into  consideration.  Fig.  5  shows 
an  occlusal  view  of  the  upper  arch  of  a  patient,  aged  twelve 


TREATMENT  OF  CARIES  39 

years,  with  cavities  in  the  right  and  left  centrals  and  laterals 
as  indicated  by  a  and  b.  It  is  obvious  that  the  insertion  of 
gold  foil  or  other  permanent  repair  is  out  of  the  question. 
A  plastic  like  oxyphosphate  of  zinc  is  here  indicated,  and 
will  be  protected  by  bands  placed  upon  the  teeth  for  their 
movement.  After  the  orthodontic  treatment  has  been 
completed  they  will  be  normally  accessible,  and  will  then 
permit  of  permanent  restoration. 

In  cases  of  extensive  caries,  requiring  crowns  and  bridges, 
the  operator  must  likewise  come  to  a  definite  conclusion 
as  to  the  most  opportune  time  for  their  insertion.  Accessi- 
bility, though  still  a  factor,  now  gives  way  to  anchorage;  for 
should  the  affected  tooth,  or  teeth,  be  required  for  anchorage 
of  the  regulating  appliance,  they  should  be  restored  before 
orthodontic  treatment  is  attempted.  Fortunately,  the 
necessity  for  such  extreme  remedial  measures  is  decreasing, 
and  their  consideration  in  orthodontic  practice  is  becoming 
extremely  rare. 

The  author  has  recently  treated  a  case  of  bilateral  disto- 
clusion,  accompanied  by  labioversion  of  the  upper  incisors, 
for  a  boy,  aged  twelve  years,  who,  owing  to  an  accident  result- 
ing in  fracture,  had  a  porcelain  crown  inserted  upon  the  left 
upper  central  during  his  ninth  year.^  The  behavior  of  the 
root  during  orthodontic  treatment  did  not  appreciably 
differ  from  those  in  which  the  pulps  were  vital.  Numerous 
similar  experiences,  therefore,  predicate  the  conclusion  that 
if  caries  has  progressed  so  as  to  affect  the  pulp,  or  to  a  stage 
demanding  an  artificial  crown,  it  should  receive  the  custom- 
ary treatment;  that  non-accessibility,  or  extreme  malposition, 
may  occasionally  postpone  the  more  permanent  restorations 
until  tooth  movements  have  been  accomplished. 

»  See  Case  K,  Figs.  207  and  208. 


40        PREPARING  THE  MOUTH  FOR  TREATMENT 

THE  EXTRACTION  OF  TEETH 

The  subject  of  the  extraction  of  teeth  prior  to  or  during 
orthodontic  treatment  divides  itself  into  that  (a)  of  tempor- 
ary teeth,  (6)  of  supernumerary  teeth,  and  (c)  of  permanent 
teeth. 

Temporary  Teeth. — Temporary  teeth  too  extensively 
decayed  to  warrant  attempts  at  conservation,  and  whose 
retention  would  seriously  affect  the  health  of  the  oral  cavity, 
should  always  be  removed  prior  to  treatment.  But  in  many 
instances,  especially  in  the  very  young,  when  several  years 
might  elapse  before  the  eruption  of  their  successors,  every 
effort  should  be  made  to  retain  them.  Again,  in  cases  of 
arrested  development  or  "contracted"  arches,  with  firm 
temporary  teeth  present  and  postponement  of  treatment 
inadvisable,  their  movement  and  subsequent  retention 
should  proceed  with  that  of  adjacent  permanent  teeth  to 
induce  growth  of  the  alveoli  and  jaws  beyond,  and  to  pro- 
mote the  normal  eruption  of  their  successors.  Extraction 
is  indicated  in  every  case  of  prolonged  retention,  provided 
there  are  no  symptoms  of  deficiency  in  the  number  of  perma- 
nent teeth,  or  where  the  successor  is  in  process  of  eruption. 

Supernumerary  Teeth.^ — Supernumerary  teeth  should  always 
be  extracted,  especially  when  they  operate  as  a  cause  of 
malocclusion.  It  is  best,  however,  to  defer  all  extractions 
until  accurate  models  have  been  constructed.  Every 
operator  should  strive  to  record  as  many  cases  as  his 
practice  affords. 

Permanent  Teeth. — The  extraction  of  permanent  teeth  for 
the  facilitation  of  the  orthodontic  treatment  is  a  question 
regarding  which  many  incisive  papers,  and  more  incisive 
rejoinders,  have  been  written.  Prior  to  the  development  of 
our  present  methods  for  the  correction  of  arch  malrelation, 


THE  EXTRACTION  OF  TEETH  41 

removal  of  certain  permanent  teeth  was  widel}'  practised, 
even  regarded  as  a  necessity.  But  with  the  perfection  of  the 
details  of  arch  movement  as  well  as  tooth  movement,  the 
group  of  cases  in  which  extraction  is  now  permissible  has 
been  greatly  restricted.  The  literature  pertaining  to  this 
subject  is  voluminous,  immensely  interesting,  and  of  the 
utmost  value,  though  the  following  two  rules  by  Professor 
Guilford^  serve  as  an  excellent  abbreviated  version  of  the 
entire  discussion. 

"1.  Do  not  decide  to  extract  until  a  careful  study  and 
restudy  of  the  case  have  been  made  from  articulated  models 
and  the  patient  in  person,  and  until  every  available  method 
of  procedure  without  extraction  has  been  carefully  con- 
sidered." 

"2.  If  extraction  seems  unavoidable,  adopt  the  best 
method  of  correction  without  it,  and  when,  in  the  course 
of  the  operation,  it  becomes  absolutely  evident  that  the 
desired  result  cannot  be  obtained  in  that  way,  it  will  still 
be  time  to  extract  and  change  our  method  of  procedure." 

Finally,  it  must  ever  be  remembered  that  the  loss  of  even 
a  single  tooth  produces  a  break  in  the  continuity  of  the  arch; 
that  the  adjoining  teeth  always  tend  to  move  toward  the 
space  thus  created;  that  the  abnormal  inclination  of  the 
adjacent  teeth  is  accompanied  by  loss  of  contact  in  more 
remote  places  in  the  arch;  that  a  reduction  in  the  size  of  the 
lower  arch  is  frequently  followed  by  a  deepening  of  the  "bite" 
and  an  increase  in  the  difficulties  of  retention;  and  that  the 
harmony  of  facial  form  rarely  permits  of  the  sacrifice.  The 
numerous  clinical  phases  of  this  subject  can  be  more  appro- 
priately dealt  with  in  subsequent  chapters  on  the  methods  of 
treatment. 

'  Orthodontia,  4th  ed.,  p.  48. 


CHAPTER    III 
KEEPING  RECORDS  OF  THE  TREATMENT 

Many  of  the  advances  in  medical  practice  have  been  based 
upon  hospital  statistics,  where  the  facilities  and  methods 
for  keeping  records  have  always  surpassed  those  adopted  by 
individual  practitioners.  It  is,  perhaps,  not  inaccurate  to 
state  that  in  dentistry  the  reverse  is  true.  Dental  clinics, 
in  most  instances,  are  usually  conducted  for  the  purpose  of 
furnishing  opportunities  for  experience  to  students  and  to 
serve  those  in  need,  being  only  incidentally  utilized  as  centres 
of  research.  It  is  but  fair  to  add,  however,  that  the  hospitals 
furnishing  the  largest  and  most  trustworthy  mass  of  clinical 
data  for  medicine  are  not,  necessarily,  the  school  hospitals; 
and  that  the  funds  at  the  command  of  such  institutions  far 
exceed  those  of  the  dental  infirmaries.  For  purposes  of 
scientific  research  it  is  always  advisable  to  procure  clinical 
data  from  both  public  and  private  records,  though  under 
existing  dental  conditions  the  private  records  of  practitioners 
are  preferable.  It  is  to  be  hoped  that  an  enlightened  interest 
in  human  health  and  an  appreciation  of  the  sociological 
significance  of  preventive  medicine  (which  should  be  provided 
for  all  the  people  by  the  strong  arm  of  the  State)  will  revolu- 
tionize this  phase  of  dental  service  in  the  not  distant  future. 

Now,  it  is  not  at  all  unusual  for  an  average  practice  to 
extend  over  a  period  of  from  thirty  to  forty  years,  thus 
affording  ample  opportunities  for  the  compilation  of  valuable 


WRITTEN  RECORDS  43 

data  upon  which  scientific  deductions  and  advances  in 
treatment  can  be  based.  It  is  exceedingly  important,  there- 
fore, that  the  beginner  adopt  some  plan  for  the  keeping  of 
records,  and  the  points  to  be  emphasized  are  that  such 
records  should  be  accurate,  concise,  and  practical.  When 
they  comply  with  these  requirements,  their  value  can  hardly 
be  overestimated.  They  should  be  so  designed  as  to  provide 
for  the  special  needs  of  an  orthodontic  practice,  which  may 
briefly  be  enumerated  as  consisting  of  written  records,  of 
plaster  models,  of  photographs  and  radiographs,  and  such 
illustrations  or  appliances  as  are  deemed  worth  recording. 


WRITTEN  RECORDS 

Among  the  many  methods  that  can  be  employed  for  the 
keeping  of  written  records,  a  specially  designed  card  system 
has  been  found  most  convenient.  It  should  be  of  standard 
size,  preferably  5x8  inches,  and  provided  with  a  filing 
cabinet  so  arranged  as  to  permit  of  comprehensive  classifi- 
cations. Figs.  6  and  7  exhibit  the  essential  items  of  such  a 
record  card.  All  of  the  scientific  phases  of  a  case,  including 
the  patient's  name  and  the  case  number,  are  placed  upon 
the  face  of  the  card.  The  reverse  side  is  arranged  for  the 
practical  phases  of  the  treatment.  Several  of  the  items  upon 
the  front  of  the  card  are  compiled  from  the  reverse  side  after 
completion  of  the  case,  or  at  the  operator's  convenience.  In 
addition,  the  author  uses  plain  ruled  cards  of  the  same  size  as 
the  record  for  the  compilation  of  all  data  of  scientific  interest. 
These  are  reclassified  by  the  use  of  extra  guides,  and  can 
be  compiled  by  any  competent  assistant. 


44     KEEPING  RECORDS  OF  THE  TREATMENT 


WRITTEN  RECORDS 


45 


46  KEEPING  RECORDS  OF   THE  TREATMENT 

This  system  of  records  renders  available  for  immediate 
use  or  study  all  the  material  his  practice  affords.  For 
example,  it  enables  one  to  instantly  state  the  number  of 
patients  of  any  given  age,  or  sex;  the  number  of  cases  where 
the  influence  of  a  given  etiological  factor  is  exhibited  in  the 
models,  e.  g.,  premature  loss  of  temporary  teeth.  All  models, 
photographs,  radiographs,  etc.,  are  numbered  and  recorded 
on  the  record  card.  Thus  all  items  of  interest  of  any  given 
case,  or  of  a  series  of  cases,  can  instantly  be  brought  together 
for  comparison  and  study. 

The  possibilities  of  the  card  system  are  so  numerous  that 
it  appeals  to  every  operator  who  values  his  records  at  their 
true  worth;  it  is  so  elastic  in  its  application  that  any  inquiry 
or  investigation  may  easily  be  carried  out  by  its  use. 


PLASTER  MODELS 

In  1756  Ph.  Pfaff  ^  introduced  the  use  of  plaster  of  Paris 
for  model  construction.  That  its  use  did  not  become 
general,  however,  is  evinced  by  the  fact  that  Kneisel,^  eighty 
years  later,  still  relied  on  sulphur,  though  both  employed 
wax  as  an  impression  material.  The  latter  frequently 
resorted  to  the  use  of  metallic  models  in  the  construction 
of  his  apphances.  These  were  made  of  fusible  alloy  and 
obtained  from  plaster  impressions  of  his  sulphur  models. 

The  construction  of  accurate  plaster  models  of  the  upper 
and  lower  teeth  and  adjacent  parts  is  now  considered  a 
necessary  detail  of  every  orthodontic  record  (Fig.  8),  and, 
as  Angle  has  clearly  emphasized,  their  value  is  enhanced  in 

'  Zahne  des  Menschl.  Korpers,  Berlin. 
2  Der  Schiefstand  der  Zahne,  Berlin,  1836. 


PLASTER  MODELS 


47 


proportion  to  their  accuracy.  To  obtain  this  accuracy 
plaster  should  invariably  be  used  for  the  impression  from 
which  the  model  is  made.  When  accompanied  by  written 
records,  they  are  of  the  greatest  scientific  value,  especially 
to  the  owner  who  is  familiar  with  many  of  the  unrecorded 
details  of  their  history. 

Fig.  S 


A  plaster  model  of  a  case  of  malocclusion  prior  to  treatment. 


Clean,  perfect  models  are  an  incentive  to  render  better 
service  and  mark  the  dividing  line  between  the  amateur 
and  artist.  They  are  absolutely  necessary  in  making  an 
intelligent  diagnosis;  are  useful  in  a  study  of  the  etiology 
and  prognosis;  and  particularly  in  planning  the  treatment 
and  designing  the  retention  appliances.  Tootli  movement 
usually  extends  over  a  period  of  several  months,  and  is  only 


48 


KEEPING  RECORDS  OF  THE  TREATMENT 


ultimately  successful  if  adequate  retention  is  provided.  The 
latter  is  an  extremely  difficult  phase  of  every  treatment,  and 
is  practically  impossible  without  the  aid  of  accurate  models 
of  the  original  conditions.  No  operator  can  afford  to  rely 
on  his  memory  as  to  the  exact  nature  of  these  original 
conditions. 

Facial  deformities  are  frequently  due  to  anomalies  of 
dentition,  and  their  correction  now  occupies  a  large  place 
in  orthodontic  practice.    A  record  of  such  service,  for  which 


Fig.  9 


Plaster  models  of  the  face  before  and  after  treatment.    (After  Case.) 

two  methods  are  at  our  disposal,  is  eminently  desirable. 
Professor  Case^  recommends  plaster  models  of  the  facial 
lines.  These  may  be  made  in  full  front  and  profile  views, 
and  are  of  natural  size  (Fig.  9).  But  the  construction  and 
filing  of  these  models  present  difficulties  which  many 
operators  have  sought  to  avoid.    This  has  given  rise  to  the 


1  Dental  Orthopedia,  Chicago,  1908. 


PHOTOGRAPHS 


49 


adoption  of  the  photographic  method,  a  process  introduced 
by  Professor  John  W.  Draper,  of  the  University  of  New 
York,  in  1839. 

Fig.  10 


Shows  size  of  the  unmounted  photographs  and  the  lines  to  which  they  are  cut  before 
mounting  on  the  record  cards. 


PHOTOGRAPHS 

When  made  according  to  certain  definite  requirements, 
photographic  records  of  the  facial  hues  answer  every  pur- 
pose, and  for  convenience  are  mounted  on  cards  of  the  same 
size  as  the  record.  The  requirements  are  simply  these: 
The  same  photographer  should  make  all  photographs  of 
4 


50     KEEPING  RECORDS  OF  THE  TREATMENT 

any  given  series;  he  should  use  the  same  lens  in  every  case 
and  adopt  a  uniform  size  and  pose.  The  prints  should 
always  be  made  upon  the  same  kind  of  permanent  paper, 
and  delivered  unmounted.  A  good  plan  is  to  instruct  the 
photographer  as  to  what  is  wanted,  laying  special  emphasis 
upon  the  fact  that  under  no  circumstances  shall  he  retouch 
any  of  the  operator's  negatives. 

To  avoid  variation  in  size,  particularly  in  the  various 
prints  of  any  given  case,  the  author  has  taken  the  precaution 
to  provide  the  photographer  with  a  card  upon  w^hich  accurate 
measurements  are  marked.  It  is  advisable  further  to  agree 
on  the  kind  of  background  to  be  used,  a  dark  ground  being 
usually  best,  because  it  affords  the  proper  contrast. 

In  mounting,  many  of  the  unnecessary  features  of  the 
prints  (such  as  dress,  shoulders,  hair  ornaments,  etc.)  may 
be  eliminated  by  using  a  pattern  cut  from  transparent 
celluloid,  and  marking  to  exact  size  before  cutting  (Fig.  10) . 
All  prints  of  any  given  case  may  then  be  mounted  upon  a  5  x  8 
card,  numbered  and  filed  in  the  cabinet  with  the  records. 

RADIOGRAPHS 

In  the  treatment  of  malocclusion  of  the  teeth  one  fre- 
quently meets  with  anomalies  of  number,  or  of  eruption  and 
form.  To  establish  certainty  in  the  diagnosis  of  such  cases 
the  a;-rays  (discovered  by  Professor  Rontgen  in  1895),  in  com- 
bination with  photographs,  are  of  the  greatest  value.  Indeed, 
for  the  elimination  of  guesswork  they  are  invaluable,  since 
by  their  use  it  is  possible  to  determine  definitely  deficiency 
or  redundancy  in  the  number  of  teeth,  and  to  ascertain 
the  peculiarities  of  anomalies  of  form  and  eruption.  The 
difficulties  encountered  in  the  movement  of  teeth  may  at 


RADIOGRAPHS 


51 


times  be  due  to  the  fusion  or  malformation  of  their  roots; 
tardy  eruption  may  occasionally  be  caused  by  perverted 
position;  a  negative  or  indefinite  history  of  premature 
extraction  rendered  intelligible,  instead  of  construed  into 


Fig.  11 


Shows  tardy  eruption  of  the  right  central  incisor  due  to  the  supernumerary  tooth 
shown  in  Fig.  12. 

Fig.  12 


vj  \\ 


Radiograph  of  case  shown  in  Fig.  11. 

deficiency  of  number.  Many  cases  might  here  be  introduced 
to  illustrate  the  wide  range  of  their  usefulness,  but  Figs. 
1 1  and  12  will  suffice,  for  they  clearly  show  the  presence  of  a 
supernumerary  tooth  as  the  cause  of  tardy  eruption  of  the 
right  upper  central  incisor  in  a  girl,  aged  eleven  years. 


CHAPTER    IV 
THE  ETIOLOGY  OF  MALOCCLUSION 

Definition. — In  medical  science,  the  study  of  the  origin  of 
disease  and  abnormahty  is  termed  etiology.  It  embraces  a 
consideration  of  all  causative  factors,  and  of  the  provisional 
theories  advocated  when  the  causes  remain  obscure.  And 
since  it  is  the  mission  of  orthodontics  /o  prevent,  as  well 
as  correct,  certain  anomalies  of  dentition,  it  is  obvious  that 
all  knowledge  relative  to  their  causation  is  of  the  very  first 
importance.  From  time  immemorial,  therefore,  observant 
operators  have  endeavored  to  ascertain  and  remove  these 
agencies,  believing  this  to  be  the  first  aim  of  every  rational 
treatment.  Unfortunately,  this  phase  of  the  art  frequently 
presents  problems  exceedingly  difficult  of  solution. 

CLASSIFICATION  OF  THE  FACTORS 

In  order  to  diminish  these  difficulties,  several  authors 
have  attempted  a  classification  of  the  etiological  factors; 
though  a  review  of  the  literatur  pertaining  to  this  subject 
impresses  one  with  the  fact  that  a  quite  general  disagreement 
yet  exists.  Some  writers  accept  the  time-honored  division 
into  hereditary  and  acquired,  finding  little  difficulty  in  formu- 
lating definitions  for  these  two  terms.  Others  exhibit  a  very 
evident  skepticism  regarding  the  "influence  of  heredity,"  and 
thus  lean  strongly  toward  the  acquired  group. 


CLASSIFICATION  OF   THE  FACTORS  53 

Heredity  and  Predisposition. — Of  course,  there  was  a  time 
when  heredity  explained  it  all,  when  it  served  as  a  cloak 
for  our  ignorance;  when  most  diseases  and  abnormalities 
were  believed  to  have  been  transmitted  from  parents  to 
offspring.  But  the  ijhysical  basis  of  heredity  (a  mechanism 
existing  within  the  germ  cell)  is  now  fairly  well  established. 
Many  of  the  recent  advances  in  biology  have  fostered  a 
strong  opposition  to  the  old  views,  forcibly  emphasizing  the 
influence  of  environmental  (acquired)  factors,  which  cannot 
be  ignored.  "As  to  the  inheritance  of  the  effects  of  extrinsic 
forces  upon  the  individual,  we  find  little  in  the  way  of  direct 
evidence.  Mutilations  of  any  sort  are  not  inherited." 
(Jordan  and  Kellogg.)  This  new^  teaching,  it  must  be 
admitted,  has  served  as  a  healthy  antidote;  it  was  needed. 

On  the  other  hand,  the  claim  of  the  opponents  of  heredity 
— "that  nature  never  transmits  the  abnormal,"  that  all 
anomalies  are  but  the  result  of  certain  lapses  in  nature's 
processes,  always  due  to  local  and  extraneous  influences — ■ 
is  equally  untenable.  In  the  light  of  modern  biological 
science  either  view  is  now  considered  extreme. 

Unfortunately,  in  these  days  of  the  "systems,"  with  their 
truly  wonderful  achievements  in  technique,  we  are  prone 
to  rest  content  with  our  superficial  calculations— for  we 
love  to  cling  to  seeming  bounds.  But  accepting,  as  we  must, 
the  physicochemical  explanation  of  life,  we  are  constrained 
to  adopt  those  causomechanical  factors  of  its  flux  which  are 
recognized  by  biologists  generally,  and  w^hich  "involve  no 
philosophical  assumptions."  These  are  heredity,  variation, 
adaptation,  selection,  isolation,  and  (probably)  mutation. 
With  the  first  of  these  we  are  here  briefly  concerned. 

Heredity  may  be  defined  as  "  the  genetic  relation  between 
successive  generations,  as  the  transference,  of  similar  char- 


54  THE  ETIOLOGY  OF  MALOCCLUSION 

acters  from  one  generation  of  organisms  to  another,  as  a 
process  affected  by  means  of  the  germ  cells."  All  peculiar- 
ities or  characteristics  that  are  imparted  to  an  individual 
through  these  germinal  cells  of  the  parents  are  spoken  of  as 
inherited.  Any  peculiarity  that  is  imparted  a'fter  conception 
has  taken  place  is  spoken  of  as  acquired.  If  before  birth,  it 
is  termed  an  intra-uterine  acquisition;  after  birth,  an  extra- 
uterine acquisition. 

All  inherited  peculiarities  are  also  said  to  be  congenital, 
whether  recognizable  at  birth  or  not.  Likewise,  all  intra- 
uterine acquisitions  are  congenital;  whereas  extra -uterine 
acquirements  are  spoken  of  as  extragenital.  The  careless 
use  of  the  term  congenital  (many  writers  believing  it  to  be 
synonymous  with  hereditary)  has  been  the  cause  of  much 
confusion. 

Concerning  predispositions,  Professor  Orth,  of  Berlin,  says: 
"Every  incapacity  of  the  body  to  resist  the  external  causes 
of  disease,  every  peculiarity  of  the  constitution  which  renders 
the  latter  unable  in  the  struggle  of  the  body  with  the  cause 
of  disease  to  maintain  the  normal  course  of  the  vital  phe- 
nomena, every  such  peculiarity  of  the  constitution  may  be 
designated  as  a  tendency,  as  a  predisposition,  to  disease. 
All  these  predispositions  to  disease  must  be  congenital  and 
inherited,  for  they  are  a  result  of  the  phylogenetic  develop- 
ment; they  have  their  origin  in  the  general  characteristics 
inherent  in  the  germ  cells.  This  conception  of  what  con- 
stitutes predisposition  to  disease  does  not  contain  anything 
mystical;  it  is  not  beyond  the  domain  of  science,  and  is  just 
as  capable  of  scientific  treatment  as  any  other  pathogenetic 
question,  though  we  must  admit  that  our  knowledge  of  the 
predispositions  to  disease  does  not  go  much  beyond  a  few 
generalities." 


INTRINSIC  FACTORS  55 

Heredity,  therefore,  is  not  as  definite  a  factor  as  formerly, 
though  we  must  continue  to  regard  it  as  of  great  importance 
in  the  study  of  organic  continuity.  "Heredity  repeats 
strength  or  weakness,  good  or  ill,  with  like  indifference." 
(Jordan  and  Kellogg.)  Furthermore,  one  phase  of  this 
vast  theme  stands  out  very  prominently,  viz.,  all  dental 
research  relative  thereto,  and  thus  far  conducted,  is  entirely 
inadequate.  For  this  reason  alone  we  should  pause  long 
before  boldly  denying  its  probable  "influence"  in  the  causa- 
tion of  malocclusion  of  the  teeth.  Another  very  plausible 
reason  why  we  should  be  less  hasty  in  excluding  the  heredi- 
tary factors  is,  that  many  anomalies  of  other  organs  of  the 
body  (notably  the  eyes,  e.  g.,  errors  of  refraction,  imbalance 
of  the  ocular  muscles,  etc.)  are  largely  congenital  and  fre- 
quently transmitted  from  generation  to  generation.  Surely, 
the  teeth  and  jaws  are  not  exempt  from  the  "influences" 
which  control  such  maldevelopments. 

"Our  present  plight  seems  to  be  exactly  this,  we  cannot 
explain  to  any  general  satisfaction"  all  the  causes  of  mal- 
occlusion of  the  teeth  without  the  help  of  some  hereditary 
factors;  "and  on  the  other  hand,  we  cannot  assume  the 
actuality  of  any  such  factor  in  the  light  of  our  present 
knowledge  of  heredity."  In  view  of  this  very  unsettled 
state  of  our  knowledge  the  author  has,  for  some  years 
past,  preferred  the  terms  intrinsic  and  extrinsic,  instead  of 
hereditary  and  acquired. 

INTRINSIC  FACTORS 

Several  anomalies  of  dentition,  and  sundry  constitutional 
peculiarities,  causing  malocclusion  of  the  teeth,  are  due  to 
certain  inherent,  systemic  influences.     We  term  these  the 


56  THE  ETIOLOGY  OF  MALOCCLUSION 

intrinsic  factors;  some  of  them  being  congenital,  and  probably 
inherited,  others  not. 

Anomalies  of  Number. — These  are  found  in  both  the  tem- 
porary and  permanent  series,  and  frequently  stand  in  causal 
relation  to  a  malocclusion.    Thus  there  may  exist  a  deficiency 

Fig.  13 


Congenital  absence  of  the  left  upper  temporary  first  molar,  permitting  the  mesioversion 
of  the  second  temporary  and  first  permanent  molars. 

in  the  number  of  teeth  (Fig.  13)  which  permits  the  adjoining 
members  to  migrate  into  abnormal  positions.  When  more 
than  twenty  teeth  appear  in  the  temporary  dentition,  or 
more  than  thirty-two  in  the  permanent,  we  term  it  redun- 
dancy. This  may  lead  to  a  crowded  arrangement  of  them  in 
tfeeir  respective  arches  (Fig.  14). 


INTRINSIC  FACTORS 


57 


According  to  Biisch/  there  are  three  kinds  of  super- 
numerary teeth:  (a)  Those  with  conical  crowns  and  root; 
(6)  tubercles;  and  (c)  supplemental  teeth,  or  those  of  normal 
form  (Hollander).  Premature  extraction  of  a  temporary 
tooth,  or  other  traumatic  influence,  might  occasionally  be 


Fig.  14 


Shows  the  result  of  redundancy  of  number;  note  the  supernumerary  tooth  between 
the  upper  centrals. 

responsible  for  a  deficiency  in  the  permanent  set,  but  it 
is  obvious  that  most  anomalies  of  number  are  not  due  to 
extraneous  causes.  Atavism  has  long  been  regarded  as  a 
cause  of  redundancy;  and  more  recently,  their  budding  off 
from  the  common  dental  lamina  has  been  suggested  as  a 
probable  explanation  of  supernumerary  teeth.    But  according 


1  Deutsch.  Monatsschr.  f.  Zahnheilk.,  1886-87. 


58  THE  ETIOLOGY  OF  MALOCCLUSION 

to  Tomes/  "our  present  knowledge  of  the  subject  will  not 
enable  us  to  recognize  the  cause  which  has  produced" 
anomalies  in  the  number  of  teeth,  though  syphilis,  rickets, 
and  other  maladies  have  frequently  been  mentioned. 

IMcQuillen,^  Tomes,'^  and  many  other  investigators  have 
recorded  numerous  cases  where  anomalies  of  number  were 
transmitted  through  several  generations  of  the  same  family. 
Fig.  15  shows  the  model  of  the  upper  arch  of  a  father  and 
Fig.  16  that  of  his  daughter,  taken  from  the  author's  collec- 
tion. Frequent!}''  the  histories  of  such  cases  are  so  vitiated 
by  premature  loss  of  teeth,  i.  e.,  by  caries  and  extraction, 
that  they  are  of  little  value.  Yet  it  is  undoubtedly  true 
that,  in  most  cases,  they  are  congenital  and  therefore 
transmissible. 

Anomalies  of  Form. — Though  rarely  met  with,  anomalies 
of  form  occasionally  enter  into  a  malocclusion,  and  they 
suggest  interesting  morphological  questions.  They  may 
express  themselves  in  various  ways,  e.  g.,  deficiency,  redun- 
dancy, dichotomes,  etc.  When  affecting  the  anterior  teeth 
they  usually  present  a  disfigurement,  and  frequently  cause 
malocclusion  of  the  adjoining  teeth.  Fig.  17  shows  the 
models  of  a  boy,  aged  nine  years,  exhibiting  a  fusion  of  the 
upper  centrals  and  laterals.  Fig.  18  illustrates  a  case  of 
redundancy  of  form  in  a  right  upper  central  incisor,  being 
fully  one-third  longer  than  the  left  central.  Irregularity  of 
size  may  also  be  complete,  affecting  the  entire  tooth,  or 
partial,  being  limited  to  the  crown  or  root. 

Abnormal  Frenum  Labium. — Occasionally,  cases  present 
themselves  with  an  abnormal  space  (diastema)  between 
the  central  incisors.*    In  the  upper  arch  it  is  usually  due  to 

>  Dental  Surgery,  5th  ed.  ^  Dental  Cosmos. 

ilbid.  <  Angle,  Dental  Cosmos,  1899. 


INTRINSIC  FACTORS 


59 


an  excessive  development  of  the  frenum  of  the  hp.     The 
fibers  of  this  muscular  attachment  are  of  sufficient  density, 


Fig.  15 


Shows  model  of  a  father  with  deficiency  in  size  of  the  right  upper  lateral,  and 
of  number  of  the  left  lateral. 


Fig.  16 


From  the  upper  arch  of  his  daughter,  exhibiting  the  same  anomalies,  though  on  the 
opposite  side  of  the  mouth. 


60 


THE  ETIOLOGY  OF  MALOCCLUSION 


and  its  movements  so  constant,  that  it  prevents  the  teeth 
from  coming  into  normal  contact. 


Fig.  17 


Anomaly  of  form  due  to  the  fusion  of  tooth  germs. 
Fig.  18 


^^^^^^mm 

1 

m        A 

K^fik, 

WaM 

til 

;W!^ 

¥jm 

"""! 

B 

Fledundancy  of  form  in  a  right  upper  central  incisor.     (After  Lukens.) 


INTRINSIC  FACTORS  61 

This  factor  is  usually  classified  as  an  acquired  cause,  or  as 
a  "local"  cause,  but  the  author  is  fully  convinced  that  this 
is  an  error.  Clinical  experience  uniformly  tends  to  show 
that  in  all  cases  brought  under  early  observation  the  same 
abnormal  conditions  exist  during  the  period  of  the  temporary 
dentition.  Wiedersheim^  has  shown  that  the  raphe  and 
gapilla  palatina^  are  more  highly  developed  in  the  embryo 
and  during  early  infancy  than  in  later  life.  This  papilla  has 
been  investigated  by  Merkel,^  who  found  it  to  be  a  sensory 
organ,  and  that  it  probably  assists  the  palatine  ridges  in 
the  trituration  of  food.  Wiedersheim  has  also  offered  the 
suggestion  that  the  raphe  is  "the  remains  of  palatal  teeth 
handed  down  even  to  man." 

In  the  absence  of  any  authentic  cases  showing  that  an 
abnormal  frenum  is  due  to  extraneous  influences,  we  are 
constrained  to  regard  it  as  an  evidence  of  faulty  develop- 
ment during  embryonic  life.  Atavism  suggests  itself  as  a 
probable  cause  of  such  faulty  development;  but  whatever 
the  cause,  it  is  plain  that  it  is  intrinsic.  Fig.  19  shows  the 
models  of  a  case,  aged  eight  years,  in  which  the  frenum  of  the 
upper  lip  was  found  to  be  the  cause  of  the  very  wide  space 
betw^een  the  upper  centrals.  Ketcham's  extended  investiga- 
tions with  the  x-rays  conclusively  demonstrate  that  such 
maldevelopments  are  in  no  wise  related  to  an  opening  of  the 
maxillary  suture. 

Cleft  Palate. — A  congenital  malformation  of  the  palate 
usually  so  interferes  with  the  development  of  the  maxilla 
that  if  allowed  to  persist  to  the  completion  of  the  permanent 
dentition  a  malocclusion  is  an  inevitable  sequela.  Fig.  20 
shows  the  models  of  a  girl,  aged  fourteen  years,  in  which 

1  The  Structure  of  Man,  p.  155. 

2  Ibid,  p.  146. 


62  THE  ETIOLOGY  OF  MALOCCLUSION 


Fig.  19 


Abnormal  frenum  labium. 
Fig.  20 


Upper  arch  of  a  case  of  malocclusion  after  an  operation  for  cleft  palate. 


INTRINSIC  FACTORS  63 

this  deformity  and  the  accompanying  malocclusion  are  very 
evident.  Fortunately,  such  cases  are  rare,  though,  as 
Bland  Sutton^  long  ago  pointed  out,  they  are  transmissible. 
He  says:  "Cleft  palate  has  been  known  to  occur  in  offspring 
of  affected  members,  and  if  it  were  possible  to  practise 
selective  breeding  in  man  as  in  dogs,  a  race  of  men  with 
cleft  palates  and  harelips  could  be  produced."  The  treat- 
ment of  the  maxillary  deformity  usually  falls  to  the  oral 
surgeon,  though  subsequent  orthodontic  interference  may 
occasionally  be  indicated.  Dr.  Dunn  has  reported  the 
treatment  of  such  a  case  to  the  American  Society  of 
Orthodontists  (Denver,  1910). 

Anomalies  of  Position. — As  already  intimated,  recent 
studies  by  orthodontists  tend  to  emphasize  the  extraneous 
influences  which  are  responsible  for  malocclusion.  There 
remain  a  few  forms  of  malposition,  however,  which  cannot 
be  attributed  to  them.  I  refer  to  transposition  and  those 
extreme  forms  of  impaction  for  which  Grevers-  has  suggested 
the  term  perversion. 

Fig.  21  shows  the  cast  of  a  denture,  sixteen  years  of  age, 
in  which  the  upper  laterals,  canines,  and  first  bicuspids  have 
exchanged  places.  Fig.  22  is  from  Dr.  Cryer's  collection, 
showing  two  impacted  canines  in  the  intermaxillary  region. 
The  causes  of  such  anomalies  are  unknown,  though  obviously 
intrinsic. 

Asymmetry  of  the  Jaws. — The  jaws,  or  foundation  structures 
upon  which  the  teeth  and  their  alveolar  processes  are  placed, 
may,  according  to  Talbot,  be  malformed  in  approximately 
30  per  cent,  of  apparently  normal  individuals.  It  is  clear 
that  if  these  structures  are  inharmoniously  developed  to 

1  Evolution  and  Disease. 

2  IV  International  Dental  Congress,  St.  Louis,  1904. 


64 


THE  ETIOLOGY  OF  MALOCCLUSION 


any  considerable  degree,  the  superimposed  teeth  are  very 
apt,  upon  closure,  to  come  into  malocclusion.     Both  the 


Fig.  21 


Transversion  of  the  upper  lateral  incisors,  canines,  and  first  bicuspids. 
Fig.  22 


Perversion  of  the  upper  canines.    (After  Cryer.) 


INTRINSIC  FACTORS  65 

upper  and  lower  jaw  may  be  thus  affected,  and  while  many 
arrests  of  development  are  traceable  to  abnormal  occlusion, 
and  therefore  abnormal  function  (which  speedily  corrects 
itself  after  orthodontic  treatment),  there  are  rare  instances 
which  cannot  be  so  easily  disposed  of.  The  causes  of  such 
developmental  disturbances  are  not  well  understood.  (See 
Chapter  V.) 

Anomalies  of  the  Tongue. — Congenital  anomalies  of  the 
tongue,  which  have  been  described  by  Virchow,  Holt,  and 
others,  exert  their  abnormal  influences  upon  the  dental 
arches,  resulting  in  deformity.  SchendeF  and  Angle^  have 
reported  cases  of  this  kind.  When  the  tongue  is  excessively 
developed  (macroglossie)  it  tends  to  enlargement  of  the 
dental  arches,  causes  a  spreading  of  the  teeth,  and  conse- 
quent loss  of  contact  with  their  neighbors.  When  arrested 
development  exists  (microglossie)  the  full  normal  influence 
of  its  muscular  action  is  absent,  which  is  usually  followed 
by  a  crowded  arch.    (Compare  Fig.  28.) 

Nutritional  and  Specific  Infectious  Diseases. — Diseases  of 
nutrition,  like  rachitis,  scorbutus,  and  marasmus,  generally 
affect  the  process  of  dentition,  though  they  are  usually  con- 
fined to  the  period  of  infancy.  Congenital  syphilis  very 
often  affects  the  permanent  teeth,  and,  according  to 
Hutchinson,  "typical  syphilitic  teeth  have  notches  in  their 
incisal  edges  and  are  dwarfed  both  as  regards  their  length 
and  breadth."  According  to  Keyes,  Black,  and  others,  such 
teeth  are  not  invariably  an  evidence  of  this  disease.  It  has 
also  been  claimed  by   Hill,^  Saleeby,^  and    other  English 


>  Deutsch.  Monatssch.  f.  Zahnheilk.,  1903. 

2  Malocclusion  of  the  Teeth,  7th  ed.,  1907. 

'  Heredity  and  Selection  in  Sociology,  London,  1907 

*  Parenthood  and  Race  Culture,  New  York,  1909. 


66  THE  ETIOLOGY  OF  MALOCCLUSION 

writers  that  racial  poisons,  like  alcohol  and  lead,  are  capable 
of  producing  malformations.  And  the  late  Herbert  Spencer^ 
suggested  the  deleterious  influence  of  vaccination  as  a  prob- 
able cause  of  the  alarming  increase  in  teeth  and  eye  affections 
among  the  inhabitants  of  Great  Britain. 


EXTRINSIC  FACTORS 

The  factors  embraced  in  this  group  are  more  readily 
recognized,  probably  because  the  operator  comes  in  daily 
contact  with  them.  A  thorough  knowledge  of  them  is  also 
imperative,  since  it  enables  one  to  successfully  combat  their 
action  and  thus  obviate  the  development  of  many  forms 
of  malocclusion. 

Premature  Loss  of  Temporary  Teeth. — ^The  necessity  for 
the  conservation  of  the  temporary  teeth  during  their  allotted 
period  is  a  truth  that  is  gaining  wide  acceptance.  The 
cumulative  evidence  of  the  disastrous  results  following  their 
early  loss  through  promiscuous  extraction,  or  neglected 
progressive  caries,  is  becoming  a  sufficient  argument  to 
all  conscientious  practitioners.  Premature  loss  and  pulp 
exposure  due  to  neglected  caries  tend  seriously  to  interfere 
with  normal  function;  and  in  the  development  of  the  denture 
and  its  related  structures  normal  function  plays  the  leading 
role.  Furthermore,  the  loss  of  a  single  tooth,  or  even  of  a 
part  of  a  tooth,  produces  a  break  in  the  continuity  of  the 
arch  and  permits  abnormal  movements  of  the  adjacent  teeth. 

Premature  Loss  of  Permanent  Teeth. — The  early  loss  of 
permanent   teeth,   especially   of  the  first   molars,   is   now 

1  Facts  and  Comments. 


EXTRINSIC  FACTORS  67 

regarded  as  an  established  etiological  factor  of  malocclusion. 
In  action  it  is  similar  to  the  loss  of  temporarry  teeth  as 
described  above,  and  is  very  frequently  accompanied  by 
a  deepening  of  the  "bite,"  or  a  destruction  of  the  normal 
plane  of  occlusion. 

Prolonged  Retention  of  Temporary  Teeth. — The  prolonged 
retention  of  temporary  teeth,  should  they  persist  long 
after  the  need  which  occasioned  them  has  ceased,  r^nother 
prolific  factor  in  the  causation  of  malocclusion.  An  erupt- 
ing tooth  is  suspended,  as  it  were,  by  its  soft  attachment 
tissues,  and  the  slightest  pressure,  if  it  be  constant,  is 
sufficient  to  deflect  it  in  its  course.  The  orifice  through 
which  a  tooth  passes  in  its  journey  of  eruption  is  greatly 
enlarged  by  the  absorption  of  the  crypt  walls.  Of  course, 
we  have  our  eruption  tables,  but  many  teeth  deviate  from 
the  averages  there  set  forth;  and  clinical  observation  teaches 
us  that  there  is  an  opportune  time  for  the  exfoliation  of 
each  temporary  tooth.  The  operator  should,  therefore, 
exercise  judgment  in  every  case  of  removal  of  temporary 
teeth.  Fig.  23,  a,  shows  the  evil  results  of  the  premature 
loss  of  temporary  molars,  permitting  the  mesial  eruption  of 
the  upper  first  molar.  Subsequently,  the  first  and  second 
bicuspids  were  also  forced  into  mesioversion,  and  thus 
encroached  upon  the  space  the  cuspid  should  occupy,  which 
came  at  a  still  later  period.  The  left  upper  temporary 
lateral  was  retained  too  long,  causing  a  linguoversion  of  its 
permanent  successor  (b) .  On  the  right  side  (c)  the  elongated 
first  molar  is  noted  coming  in  contact  with  the  lower  gingival 
ridge,  which  is  due  to  the  early  loss  of  the  lower  first  perma- 
nent molar. 

Nasal  Obstruction. — ^The  importance  of  normal  respira- 
tion and  of  a  rational  nasal  hygiene,  particularly  during 


THE  ETIOLOGY  OF  MALOCCLUSION 


Fig.  23 


a,  mesioversion  of  the  upper  permanent  molar  resulting  from  premature  loss  of 
temporary  molars;  6,  linguoversion  of  the  upper  lateral  due  to  prolonged  retention  of 
its  predecessor;  c,  beginning  supraversion  of  an  upper  molar  which  has  been  deprived 
of  occlusal  contact. 


EXTRINSIC  FACTORS  69 

the  developmental  period,  can  hardly  be  overestimated. 
"Obstruction  of  the  free  passage  of  air  through  the  nose 
is  one  of  the  most  frequent  and  important  consequences  of 
nasal  disease.  The  obstruction  may  be  partial  or  complete, 
periodical  or  constant.  When  chronic  nasal  obstruction 
occurs  at  an  early  age,  it  exercises  deleterious  effects  on  the 
neighboring  parts,  on  the  general  well-being,  and  on  the 
development  and  growth  of  the  whole  body.  The  full 
consequences  of  nasal  obstruction  are  most  frequently  seen 
in  children  suffering  from  adenoids."  It  may  be  due 
to  one  or  more  of  the  following  anomalous  conditions: 
(a)  Adenoids,  (6)  deforviities  of  the  septum,  (c)  hyper- 
trophies of  the  turbinates,  and  (d)  nasal  polypus.  Another 
condition  frecj[uently  met  with,  and  ver}'  often  associated 
with  lymphoid  hyperplasia  of  the  nasopharynx,  is  hyper- 
trophy of  the  tonsils,  constituting  an  hypertrophy  which 
includes  what  has  been  called  the  "lymphoid  ring,"  or 
"ring  of  Waldeyer." 

~TKe'~more  important  direct  effects  of  nasal  obstruction 
Lack^  places  as  follows:  Loss  of  nasal  function,  the  open 
mouth  and  its  mechanical  consequences,  deficient  oxygenation 
of  the  blood,  and  deformity  of  the  chest  walls.  The  symptoms 
due  to  a  constantly  open  mouth,  and  which  especially 
appeal  to  the  orthodontist,  he  enumerates  thus:  The  typical 
fades,  malformation  of  the  jaws,  malposition  of  the  teeth, 
and  collapse  of  the  alee  nasi. 

In  Figs.  24  and  25  are  shown  the  models  and  photographs 
of  a  girl,  aged  twelve  years,  which  are  typical  of  the  conditions 
under  discussion.  In  his  very  able  investigation  of  this  type 
of  deformity  Lack  concludes  as  follows: 

"  Diseases  of  the  Nose,  p.  56. 


70 


THE  ETIOLOGY  OF  MALOCCLUSION 
Fig.  24 


Malocclusion  resulting  from  nasal  obstruction. 
Fig.  25 


'•r. 


Facial  deformity  accompanying  case  shown  in  Fig.  24. 


EXTRINSIC  FACTORS  71 

"Thus  most  observers  agree  that  the  deformities  in 
question  are  frequently,  if  not  invariably,  associated  with 
mouth  breathing.  Ziem's  experiments  demonstrate  con- 
clusively that  they  may  result  from  it.  He  obstructed  the 
nostrils  of  puppies  and  other  young  animals,  and  found  that 
great  deformity  of  the  bones  of  the  face  resulted  in  later 
life.  There  seems  every  reason  to  believe  that  nasal  obstruc- 
tion precedes  and  causes  the  facial  deformity.  The  latter 
is  never  congenital,  but  it  follows  after  years  of  mouth 
breathing;  the  changes  can  be  arrested,  and  will  even  retro- 
gress, if  the  cause  be  removed." 

Vertical  and  mesial  malrelations  of  the  lower  dental  arch, 
and  malformation  of  the  mandible,  are  frequently  associated 
with  mouth  breathing.  Case^  suggested  the  latter  as  a  cause, 
and  that  hypertrophy  of  the  tonsils  frequently  stands  in 
causal  relation  to  them. 

But  the  subject  of  nasal  obstruction  is  a  vast  one,  forming 
a  large  part  of  the  field  of  rhinology,  and  it  would  carry  us 
far  beyond  the  confines  of  the  present  chapter  to  attempt  a 
detailed  treatment  of  it.  For  further  study,  the  student  is 
referred  to  text-books  on  diseases  of  the  nose  and  throat. 

Habits. — Another  rather  fruitful  cause  of  malocclusion  are 
sundry  habits  of  childhood.  Foremost  among  these  may  be 
mentioned  the  habits  of  thumb  and  tongue  sucking,  and 
that  of  lip  biting.  The  first  is  probably  the  most  common, 
and  very  frequently  hardest  to  discontinue.  They  are 
usually  acquired  during  infancy,  when  the  parents  or  nurse 
regard  them  as  harmless,  or  even  pleasing.  But  when  we 
reflect  on  the  mechanics  of  maxillary  development,  on  the 
ease  with  which  growing  tissues  are  moulded  into  form,  and 

1  Dental  Review,  July,  1894. 


Fig.  26 

^^^    ,_^M^^^^^ 

^^ 

ivA 

^^gUjj^^/l//^^^ 

HKfrfS 

^ 

1 

Thumb  sucking. 
Fig.  27 


Lip  biting. 


EXTRINSIC  FACTORS  73 

on  the  constancy  of  these  subtle  influences,  we  readily  appre- 
ciate their  gravity  and  soiu'ce  of  harm  when  continued  for  a 
long  period.  Fig.  26  shows  the  influence  of  thumb  sucking, 
causing  the  labioversion  of  the  upper  incisors  and  the  lingual 
inclination  of  the  lower.     The  constant  biting  and  sucking 

Fig.  28 


Tongue  sucking. 

of  the  lower  lip  causes  similar  deformity,  as  shown  in  Fig.  27. 
Tongue  sucking,  though  less  common,  permits  the  elonga- 
tion of  the  posterior  teeth  (allowing  an  abnormal  elevation 
of  their  occlusal  planes)  and  prevents  the  normal  contact  of 
the  anterior  teeth.    Fig.  28  shows  a  case  of  this  type. 

Some  writers  have  classified  mouth  breathing  as  a  habit, 


74  THE  ETIOLOGY  OF  MALOCCLUSION 

though  it  is  obvious  that  it  is  but  a  symptom  of  pathological 
conditions  of  the  respiratory  tract.  Herbst^  also  mentions 
the  probable  influence  of  the  following,  which  are  frequently 
overlooked:  The  use  of  pacifiers  during  infancy,  the  sucking 
of  cheeks,  the  biting  of  the  upper  lip  in  mesioclusion  of  the 
lower  arch,  resting  the  cheeks  upon  the  hands,  resting  the 
chin  upon  the  hand,  and  sleeping  on  one  side.  According  to 
this  author,  Peckert  has  suggested  the  biting  of  cigar  tips 
as  practised  by  cigarmakers;  Palltorf  the  biting  of  threads 
among  seamstresses;  the  playing  of  musical  instruments 
like  the  flute,  etc.,  and  the  artificial  deformities  of  the  teeth 
as  practised  by  many  primitive  races  (Schroder),  as  causing 
deformities  of  secondary  importance. 

Accidents  and  Traumatic  Influences. — Falls,  or  violent 
blows  upon  the  teeth,  and  fractures  of  the  alveolar  processes 
and  maxillae,  may  cause  malocclusion  if  their  treatment  is 
neglected;  though  Angle  and  other  writers  have  conclusively 
shown  that  such  deformity  can  readily  be  prevented  if  the 
proper  treatment  is  provided.  Tomes^  reports  a  case  of 
malocclusion  accompanied  by  malformation  of  the  mandible, 
in  a  patient,  aged  twenty-one  years,  which  was  due  to  a 
burn  about  the  neck  and  chest  at  the  age  of  five.  Fig.  29, 
taken  from  the  author's  collection,  shows  the  casts  of  a 
youth,  aged  eighteen  years,  who  was  kicked  in  the  mouth 
by  a  mule  during  his  eighth  year. 

Dr.  Chilcott,^  of  Bangor,  Me.,  presents  a  paper  in  which 
he  describes  an  "Obstetrical  Deformity  of  the  Mandible," 
which  he  attributes  to  a  breech  presentation.  Jt  is  claimed 
that  such  presentations  may  cause  a  straightening  of  the 

■  Zahnarztl.  Orthopadie,  p.  84. 

2  Dental  Surgery,  5th  ed.   p.  166. 

3  Dental  Cosmos,  March,  1906. 


EXTRINSIC  FACTORS  75 

mandible,  resulting  in  mesioclusion  of  the  lower  arch  and 
malformation  of  the  mandible. 

Fia.  29 


Malocclusion  due  to  an  accident. 

Pericemental  Affections. — It  is  well  known  that  chronic 
infections  of  the  pericementum  and  alveolar  processes, 
commonly  termed  pyorrhea  alveolaris,  or  alveolitis,  may 
cause  malposition  of  the  teeth.  Fig.  30  shows  the  cast  of  a 
denture,  thirty-eight  years  old,  in  which  the  upper  incisors 
were  the  seat  of  such  infection,  and  which  had  gradually 
caused  their  labial  movements  during  a  period  of  two  years. 
The  distoclusion  of  the  lower  arch  (which  is  evident)  must 
not,  however,  be  attributed  to  this  cause,  but  to  nasal 


76  THE  ETIOLOGY  OF  MALOCCLUSION 

obstruction  in   childhood,   which  the  history  of  the  case 
clearl}^  established. 

Fig.  30 


BB 

jH^^^^^ 

^^^^ 

^\ 

^^^^"''^K^ 

^^^m               rm 

lWl'*hr-TBrt« 

Hm 

m^^ 

r  -      -.^ 

^H^^'y^ 

■4   - 

K,  '\ 

^^^^^-  '*«»"4>~..  ite^.**--'*'*^'"^ 

M   V^'" 

-'^■^: 

^^^.. 

lly^ 

-  jcf"^  .J 

r 

^ 

Malalignment  due  to  alveolitis. 
Fig.  31 


Hyperplastic  formation  of  connective  tissue  preventing  the  eruption  of  a 
lower  bicuspid. 

Neglected  progressive  caries  of  the  deciduous  teeth  usuallj^ 
leads  to  pulp  exposure  and  infection,  and  to  chronic  abscesses 


UNKNOWN  FACTORS  77 

discharging  in  a  sinus.  At  the  meeting  of  the  Missouri 
State  Dental  Association  for  1906,  the  author  reported  a 
case  of  a  j^outh,  aged  sixteen  years,  who  suffered  from  such 
neglect  during  his  eighth  year.  The  point  of  infection  was 
in  the  left  lower  deciduous  first  molar,  and  caries  soon 
destroyed  all  of  the  remaining  tooth  tissue  that  was  not 
resorbed.  The  membranous  surfaces  of  the  adjacent  tissue 
being  inflamed,  together  with  a  cessation  of  suppuration, 
so  coalesced  as  to  result  in  a  fibrous  adhesion.  This  hyper- 
plastic formation  of  connective  tissue  caused  the  impaction 
of  the  first  bicuspid,  completely  preventing  its  eruption 
(Fig.  31). 

Disuse  and  Artificial  Nursing. — Disuse  of  the  dental  organs 
during  childhood  or  the  developmental  period,  and  the 
artificial  nursing  of  infants,  are  frequently  mentioned  as 
causes  of  arrested  development  of  the  maxillse  and  their 
processes.  The  modern  methods  of  cooking  food  and 
neglected  caries  are  also  said  to  be  largely  responsible  for 
the  prevalent  practice  of  improper  mastication. 

In  his  study  on  The  Mechanical  Formation  of  the  Denture, 
Korbitz^  has  carefully  analyzed  such  influences  as  active 
muscular  pressure;  the  passive  pressure  of  the  soft  parts; 
atmospheric  pressure;  pressure  of  the  adhering  tongue,  as 
noted  by  Cryer;  the  functional  influence  of  occlusion,  etc., 
all  of  which  are  minimized,  or  even  perverted,  in  cases 
where  the  above-mentioned  factors  are  operative. 

UNKNOWN  FACTORS 

The  author  has  tried  to  enumerate  all  of  the  accepted 
factors  of  causation,  yet  he  realizes  that  the  facts  here 

'  Oegt.-Ungar.  Vierteljahrgch.  f.  Z^hnheilk.,  1900. 


78  THE  ETIOLOGY  OF  MALOCCLUSION 

presented  form  but  the  merest  outline  of  this  subject.  The 
problems  of  causation  represent  a  field  so  vast  that  its 
boundary  lines  are  hardly  discernible.  Many  of  the  truths 
therein  enclosed  are  reserved  for  future  investigation.  Some 
of  the  causes  already  mentioned,  and  others  less  generally 
accepted,  might  quite  advantageously  be  grouped  into  a 
class  and  labeled  as  unknown. 

Some  authors  contend  that  civilization  is  a  cause,  that 
our  modes  of  life  in  contrast  with  primitive  man  make  for 
retrogression  and  degeneration.  But  there  is  little  in  the 
way  of  direct  evidence  regarding  this,  and  it  is  probably 
only  "one  of  those  delightfully  vague  suggestions  which 
are  thoughtlessly  advanced."^  Wallace  very  significantly 
adds:  "Knowing,  as  we  do,  that  'thousands'  of  Chinese 
skulls  have  been  examined,  and  only  one  trivial  case  of 
irregularity  has  been  observed,  and  knowing  also  that  the 
Chinese  belong  to  the  most  ancient  civilization  extant,  and, 
further,  having  been  taught  that  irregularities  are  frequent 
among  Hawaiians,  we  must  be  careful  about  laying  too  much 
credence  on  the  idea  that  civilization  is  anything  more  than 
a  frequent  concomitant  of  irregularities." 

Race  mixture  has  been  suggested  as  a  cause,  especially  in 
America,  which  has  very  aptly  been  called  "The  Melting 
Pot."  It  has  been  claimed  that  in  mixed  types,  "the  product 
of  a  cross  between  a  broad-  and  a  long-headed  race,  one 
contributes  the  head  form,  while  the  other  the  facial  pro- 
portions." Anthropologists  have  frequently  reported  dis- 
harmonisms  of  this  kind,  but  the  data  upon  which  similar 
deductions  regarding  the  teeth  are  based  are  very  scanty. 

In  conclusion,  it  may  be  worth  emphasizing  the  one  great 

I  Wallace,  Irregularities  of  the  Teeth,  p.  98. 


UNKNOWN  FACTORS  79 

difficulty  confronting  investigations  of  this  kind,  viz.,  the 
lifetime  of  an  observer  is  too  brief  to  comprehend  more  than 
three  generations;  and  even  in  cases  where  this  is  possible  the 
data  are  frequently  so  vitiated  that  they  are  of  little  value. 
Our  greatest  hope  for  the  future,  therefore,  must  lie  in  the 
realm  of  experiments  on  the  lower  animals. 


CHAPTER   V 

THE  DIAGNOSIS  OF  MALOCCLUSION 

FIRST  PRINCIPLES 

The  dental  axiom  that  only  a  normal  denture  can  perform 
normal  functions  is  gaining  wide  acceptance.  This  not  only 
implies  immunity  to  caries  and  the  absence  of  sundry  lesions 
of  the  oral  tissues,  but  a  denture  whose  architectonic  form 
approaches  the  ideal.  To  perform  the  complex  functions  in 
response  to  which  the  teeth  were  brought  into  being,  they 
develop  characteristic  forms  and  assume  very  appropriate 
anatomical  positions.  An  intimate  knowledge  of  these  fine 
symmetrical  relations  is  ver}^  essential  in  orthopedic  practice, 
for  in  the  correction  of  every  malocclusion  we  are  confronted 
with  the  two  queries: 

(a)  What  is  the  nature  and  extent  of  the  abnormality  to 
be  corrected? 

(6)  What  is  the  condition  we  wish  to  establish? 

Ultimately,  these  inquiries  always  lead  us  to  ask  the 
further  questions: 

(c)  What  movements  will  be  necessary? 

id)  What  method  of  treatment  will  best  accomplish  these 
movements? 

To  the  beginner  the  selection  of  the  remedy,  or  the  answer 
to  question  {d),  seems  most  important;  but  it  requires  very 
little  experience  to  show  that  this  is  an  error,  and  that  the 
only  logical  approach  to  the  problems  is  in  the  order  in 
which  they  are  here  presented. 


FIRST  PRINCIPLES 


81 


The  answer  to  the  first  query  (a)  imphes  an  accurate 
diagnosis,  an  interpretation  of  the  abnormahty  on  a  basis 
of  normahty;  and  since  the  aim  of  every  treatment  is  the 
estabhshment  of  normal  relations,  the  significance  of  what 
constitutes  a  normal  denture  becomes  evident. 

The  arrangement  of  the  teeth  in  the  form  of  two  parabolic 
curves  within  the  alveolar  processes  of  the  jaws  is  called  their 
alignment.    When  a  tooth  deviates  in  its  position  from  this 

Fig.  32 


Alignment  and  malalignment. 

ideal  line,  it  is  said  to  be  in  malalignment,  or  malposition 
(Fig.  32).  When  brought  together  in  the  act  of  mastication, 
normally  arranged  teeth  are  found  to  interdigitate  very 
accurately.  This  intimate  relationship  existing  between  the 
cusps  of  the  lower  teeth  in  normal  contact  with  those  of  the 
upper  is  termed  occlusion.  It  is  a  primal  function  of  the 
teeth,  and  is  dependent  upon  their  position.  When  a  tooth 
occupies  an  abnormal  position,  and  hence,  on  closure,  comes 
into  abnormal  contact  with  its  antagonists,  it  is  said  to  be 
6 


82  THE  DIAGNOSIS  OF  MALOCCLUSION 

in  malocclusion  (Fig.  33).  The  latter  is  a  generic  term  used 
to  collectively  designate  the  various  abnormal  forms  of 
occlusion.  Occasionally,  teeth  assume  such  extreme  mal- 
positions that  they  are  actually  in  non-occlusion,  failing  in 
contact  with  their  antagonists  (Fig.  28). 

Malocclusion  of  the  teeth  presents  itself  in  an  almost  end- 
less variety  of  forms,  and  for  many  years  it  was  an  accepted 
belief  that  their  classification  constituted  a  hopeless  task. 
Fortunately,    numerous    investigators    were    not    similarly 

Fig.  33 


Occlusion  and  maloccluaion. 

minded,  but  endeavored  to  bring  order  into  this  apparent 
confusion,  to  detect  similarity  in  so  vast  a  number  of  devia- 
tions from  normality.  They  realized  that  a  comprehensive 
classification  constituted  the  main  problem  in  the  difficult 
art  of  diagnosis,  and  hence  devised  systems  for  this  purpose. 
The  first  recorded  attempt  was  by  the  German  dentist, 
Kneisel,^  who  proposed  the  two  groups,  partial  and  complete. 

'  Der  Schiefstand  der  Zahne,  Berlin,  1836. 


DEFINITION  83 

By  the  term  'partial,  he  ment  malposition  of  the  individual 
teeth;  and  by  compkie,  he  had  reference  to  the  abnormal 
relations  of  the  dental  arches.  From  among  the  many 
other  methods  proposed  since  then,  we  may  mention  those 
by  the  following  authors  as  the  most  important:  Carabelli/ 
Magitot,^  Iszlai,^  Sternfled/  Angle/  Welcker/  Grevers,^ 
Herbst,^  Zsigmondy,^  and  Villain.'" 

Most  of  these  efforts  at  conceptual  shorthand  are  more 
or  less  comprehensive,  and  are  largely  based  upon  patho- 
logical manifestations.  Many  others  proposed  from  time 
to  time  were  based  upon  the  treatment  to  be  instituted,  and 
were,  needless  to  state,  fallacious.  Furthermore,  several 
of  these  schemes  contained  proposals  for  an  improvement 
in  our  nomenclature,  embracing  systems  of  terms  which, 
by  their  very  etymology,  would  convey  a  picture  of  the 
conditions  implied.  But  desirable  as  such  efforts  appear, 
they  have  not  altogether  removed  our  difficulties,  and,  at 
the  present  writing,  not  one  of  them  has  gained  universal 
acceptance. 

DEFINITION 

Broadly  interpreted,  every  diagnosis  implies  a  considera- 
tion of  several  general  conditions,  e.  g.,  the  age,  general  and 
oral  health  of  the  individual,  the  relative  degree  of  growth 
and  development,  the  recognition  of  causative  factors,  etc. 

'  Handbuch  der  Zahnhl.,  Wien,  1844. 

2  Traits  des  anomalies  du  systSme. 

3  Internat.  Med.  Cong.,  London,  1S81. 

^  Ueber  Biszerten  und  Bisanamolien,  Miinchen,  1888. 
'  Dental  Cosmos,  1899. 
^  Archiv  f.  Anthropologie,  1902. 
"  IV  Internat.  Dental  Cong.,  St.  Louis,  1904. 
s  Deutsch.  Zahnarztl.  Woch.,  1904. 
'  Oestr.  Zeit.  f.  Stomatologie,  Wien,  1905. 
'»  Zeit.  f.  Zahnarztl.  Orthopadie,  Berlin,  1910. 


84  THE  DIAGNOSIS  OF  MALOCCLUSION 

Custom,  however,  limits  the  use  of  the  term  to  the  art  of 
differentiating  one  affection  from  a  group  of  abnormahties 
having  similar  symptoms.  Thus  in  orthodontic  practice  it 
embraces:  (a)  The  distinguishing  of  one  form  of  mal- 
occlusion from  another;  (b)  the  detection  of  anomalies  of 
dentition  (and  of  the  jaws  and  related  structures)  other  than 
those  of  position  and  occlusion;  and  (c)  the  degree  of  facial 
deformity  associated  therewith. 

GENERAL  OUTLINE  OF  THE  ANOMALIES  OF 
DENTITION 

In  1877  the  French  dentist  Magitot^  proposed  a  com- 
prehensive scheme  for  the  many  deviations  from  normality 
found  in  the  denture  of  man.  Though  based  upon  the 
records  of  2000  cases,  it  was  formulated  prior  to  the  introduc- 
tion of  many  of  our  present  methods  of  treatment,  which 
latter  have  greatly  extended  the  field  of  dental  orthopedics. 
He  therefore  omitted  mention  of  the  deformities  of  the 
facial  lines,  and  of  the  maxillary  structures  beyond  the 
teeth,  presenting  a  classification  substantially  as  follows: 
(a)  Anomalies  of  eruption;  (b)  anomalies  of  number;  (c) 
anomalies  of  form  and  structure;  and  (d)  anomalies  of 
position. 

The  anomalies  of  eruption  may  be  further  classified  into 
premature  and  tardy;  those  of  number,  into  deficiency  and 
redundancy;  those  of  form  and  structure,  into  partial  and 
complete,  etc.  Orthodontic  art  occupies  itself  largely  with 
the  correction  of  what  Magitot  termed  the  anomalies  of 
position,  but  it  should  not  be  forgotten  that  any  of  the  other 
forms  mentioned  above  (and  anomalies  of  the  jaws)  may  be 
found  associated  with  them. 

1  Traits  des  anomalies  du  systeme. 


THE  DIFFERENTIATION  OF  THE   VARIOUS  FORMS     85 


THE  DIFFERENTIATION  OF  THE  VARIOUS  FORMS 

Let  us  first  ask  ourselves,  What  conditions  usually  enter 
into  a  malocclusion?  The  answer  to  this  question  must  be 
stated  as  follows:  There  are  just  three  conditions  which 
may  conjoin  in  a  malocclusion — conditions  so  fundamental 
that  most  writers  now  recognize  their  basic  significance — 
and  each  one  of  these  conditions  is  reducible  into  element- 
ary divisions,  regardless  of  their  manifold  combinations. 
Concisely  expressed,  these  three  conditions  are:  (1)  Mal- 
formation  of  the  jaws  and  their  ijrocesses;  (2)  malrelation  of 
the  dental  arches;  and  (3)  malposition  of  the  teeth.  Let  us 
briefly  consider  these  three  conditions  in  the  order  of  their 
gravity. 

Malformation  of  the  jaAvs  is  the  most  serious  condition 
we  have  to  deal  with,  and  at  times  constitutes  a  deformity 
so  severe  that  its  correction  lies  outside  of  our  domain. 
Therefore,  when  a  case  presents  a  pronounced  malformation 
of  one  or  both  jaws,  it  should  be  emphasized  and  receive  first 
mention  in  the  naming  of  the  deformity  (Fig.  34) . 

If  we  could  remove  all  of  the  soft,  overlying  tissues  from 
the  mandible  in  such  a  case,  exposing  it  to  full  view,  there 
can  be  no  doubt  that  the  general  deformit}^  of  this  bone,  and 
not  the  superimposed  teeth  and  their  occlusion,  would  attract 
our  first  attention  (Fig.  35) .  And  as  we  ponder  over  it,  how 
futile  all  orthodontic  efforts  at  correction  would  seem, 
especially  if  they  blindly  ignored  this  foundation.  Of  course, 
the  age  of  the  patient  is  an  important  factor  in  the  treatment 
of  these  cases;  and  recent  developments  in  the  methodology 
of  our  art  have  established  the  fact  that  early  treatment 
of    malocclusion    (by    securing    normal    dental    function), 


Fig.  34 


Mandibular  macrognathism. 
Fia.  35 


Shows  the  maloccltision  of  Fig.  34.    The  bilateral  mesioclusion  is  but  a 
symptom  of  the  jaw  deformity. 


THE  DIFFERENTIATION  OF  THE  VARIOUS  FORMS     87 

invariably  corrects  the  menacing  deformity  beyond  the 
teeth  and  their  alveoli. 

It  is  obvious,  moreover,  that  malformations  of  the  jaws 
may  express  themselves  in  several  ways,  hence  it  is  desirable 
to  enumerate  the  various  kinds  and  to  adopt  a  satisfactory 
terminology.  Now,  medical  literature  has  for  years  recog- 
nized the  congenital  deformities  of  the  jaws  under  the 
group-term  polygnatJiism,  embracing  epignathism,  agnathism, 
hypognathism,  etc.  And  continental  European  writers  have 
used  the  ending  gnathia  (meaning  jaw)  quite  liberally,  so 
that  it  is  not  entirely  new  in  dental  science.  The  author, 
therefore,  suggests  its  adoption  in  this  connection. 

Deformities  of  the  jaws  may  unfold  themselves  as  over- 
developments, for  which  the  term  macro gnathism  serves 
admirably;  or  they  may  express  themselves  in  arrested 
development,  in  which  case  it  is  termed  micrognathism. 
When  confined  to  the  upper  jaw,  it  may  be  indicated  by  the 
word  maxillary;  or,  if  confined  to  the  lower,  it  is  termed 
mandibular.  When  both  jaws  are  similarly  affected,  the 
term  himaxillary  is  used.  Furthermore,  the  author  is  of 
the  opinion  that  these  terms  should  only  be  used  for  those 
extreme  deformities  which  are  not  amenable  to  orthodontic 
procedure. 

The  arrangement  of  the  teeth  in  the  form  of  two  arcades 
or  graceful  curves  (an  upper  and  lower,  each  with  its  right 
and  left  sides)  demands  a  fine  adjustment  of  the  individual 
members  of  each  if  a  symmetrical,  well-balanced  ensemble 
is  to  be  established.  Bearing  in  mind  that  we  are  here 
dealing  with  bilateral  symmetry,  we  can  readily  see  how  all 
of  the  upper  teeth,  or  all  of  the  lower,  could  be  in  perfect 
alignment  in  their  respective  arches,  and  yet,  on  closure, 
fail  to  come  into  normal  occlusion.     In  other  words,  either 


88  THE  DIAGNOSIS  OF  MALOCCLUSION 

arch  (even  though  it  retain  a  normal  form)  may  be  so 
displaced  upon  its  osseous  base  that  normal  contact  with 
antagonists  becomes  impossible.  We  term  this  condition 
arch  malrelation  (Fig.  36).  It  is  obvious  that  this  is  invari- 
ably accompanied  by  malposition  of  the  teeth,  though  the 
latter  frequently  exists  without  the  former.  Differently 
expressed,  in  cases  of  simple  malposition,  accompanied  by 
normal  relation  of  the  arches,  we  have  to  deal  only  with 
anomalies  of  arch  form. 

Since  the  publication  of  Kneisel's  book  many  writers  have 
recognized  a  few  of  the  various  forms  of  arch  malrelation, 
but  it  remained  for  Angle  to  emphasize  their  far-reaching 
significance  and  to  discover  the  unilateral  and  bilateral 
deviations.  He  also  proposed  diagnostic  points,  by  means 
of  which  the  mesial  and  distal  variations  may  easily  be 
detected.  The  mesiodistal  relationship,  or  occlusion,  of  the 
first  permanent  molars  is  thus  made  to  serve  as  an  aid  in 
the  diagnosis  of  the  mesial  and  distal  forms.  Of  course,  in 
mutilated  cases  allowance  must  be  made  for  the  possible 
abnormal  position  of  these  teeth. 

Angle's  Classification. — Of  all  the  schemes  alluded  to 
above,  the  Angle  classification  is  the  most  widely  accepted. 
It  proposes  a  division  of  all  forms  of  malocclusion  into  three 
classes  as  follows : 

Class  I.     Normal  mesiodistal  relation  of  the  arches. 

Class  II.     Distal  relation  of  the  lower  arch. 

Class  III.     Mesial  relation  of  the  lower  arch. 

In  its  essence,  therefore,  it  is  a  classification  based  upon 
the  relations  of  the  two  dental  arches  (an  exceedingly  impor- 
tant distinction),  though  its  numerical  terminology  does 
not  indicate  this. 

Now,   in  a   consideration  of  arch  relation  we  base  our 


THE  DIFFERENTIATION  OF  THE  VARIOUS  FORMS     89 

differentiation  upon  normal  closure,  or  occlusion,  hence 
the  ending  elusion  may  readily  serve  us  in  our  terminology 
for   designating   the   various   forms.      To   this   ending   we 

Fig.  36 


B 


Normal  and  abnormal  arch  relation.  A  is  diagrammatic  of  their  normal  relation,  as 
indicated  by  the  plane  a,  b,  c,  and  d;  in  B  their  relation  in  a  bilateral  mesioclusion  is  set 
forth,  the  perpendicular  b  x  indicating  the  normal.  The  line  6  y  suggests  their  relation 
in  distoclusion. 


prefix  well-known  anatomical  terms,  and  thus  get  the  fol- 
lowing: Mesioclusion,  when  the  lower  arch  is  mesial  in 
its  relation  to  the  upper  (Fig.  36) ;  distoclusion,  when  it  is 


90 


THE  DIAGNOSIS  OF  MALOCCLUSION 


distal  to  normal  (Fig.  37).    As  stated  above^  both  sides  of 
an   arch   may  be   affected,  when   it  is  termed  a  bilateral 


Fig.  37 


Bilateral  distoclusion  complicated  by  liuguoversion  of  the  upper  central  inciso'^s. 


THE  DIFFERENTIATION  OF  THE  VARIOUS  FORMS     91 

inrshrlusion  or  disforhmnn.     Or,  if  only  one  side  is  involved, 
we  term  it  a  iinihtfmil  wcslocJn.von  or  (Usindimon  (Fig.  38). 


Fig.  38 


Unilateral  distoclusion. 


92  THE  DIAGNOSIS  OF  MALOCCLUSION 

In  a  consideration  of  1000  cases  of  malocclusion,  Angle 
found  692  in  which  the  mesiodistal  relations  of  the  arches 
were  normal,  the  main  difficulty  being  a  malposition  of  the 
individual  teeth,  or  an  anomaly  of  arch  form.  In  other 
words,  one  or  more  teeth  were  in  malalignment,  hence  mal- 
occlusion, a  condition  recognized  by  all  writers  and  loosely 
termed  "irregularities."  That  there  were  several  kinds  of 
malposition  was  generally  known,  but  again  it  remained  for 
Angle  to  enumerate  seven  primary  forms,  and  to  call  special 
attention  to  their  possible  combinations.  Unhappily,  this 
writer  has  become  so  enamored  of  the  w^ord  occlusion  that 
he  makes  it  serve  in  this  instance  by  prefixing  anatomical 
terms  to  it  for  the  designation  of  these  seven  deviations. 
The  author  firmly  believes  that  it  would  be  a  distinct 
advance  if  an  ending  denoting  position  were  used  instead, 
because  the  spoken  word  should  be  measurably  descriptive. 

Again,  having  adopted  the  ending  elusion  as  appropriate 
for  the  designation  of  malrelation  of  the  arches,  it  becomes 
necessary  to  use  another  term  to  denote  malposition  of  the 
individual  teeth.  Hence  the  author  suggests  that  the  widely 
used  medical  ending  version  (Lat.  vertere,  to  turn,  to  change 
position)  be  used  to  denote  malposition  of  individual  teeth. 
This  gives  the  following  terms:  Labioversion  or  huccoversion 
to  denote  labial  or  buccal  malposition;  linguoversion,  when 
a  tooth  is  lingual  to  normal;  mesioversion,  when  mesial  to 
normal;  distoversion,  when  distal  to  normal;  torsoversion, 
when  rotated  on  its  axis;  swpr aversion,  to  denote  elongation; 
infr aversion,  for  depression  (Fig.  28) ;  perversion,  for  impacted 
teeth  (Fig.  22);  and  transversion,  for  transpositions  (Fig.  21). 

Now,  the  mere  fact  that  approximately  70  per  cent,  of  all 
forms  of  malocclusion  exhibit  neither  extreme  malformation 


THE  DIFFERENTIATION  OF  THE   VARIOUS  FORMS     93 

of  the  jaws  nor  mesial  or  distal  malrelation  of  the  arches, 
emphasizes  the  advantage  of  a  separate  term  for  this  large 


Fia.  39 


Typical  neutroclusion. 


94  THE  DIAGNOSIS  OF  MALOCCLUSION 

class  (Class  I,  Angle).     The  author/  therefore,  suggested 
that  the  word  neutroclusion  (Lat.  neutro,  in  neither  direction; 

Fig.  40 


Neutroclusion  complicated  by  extreme  labioversion  of  the  upper  inciaors. 
■  Dental  Cosmos,  April,  1911. 


THE  DIFFERENTIATION  OF  THE  VARIOUS  FORMS     95 

occlmio,  to  close)   be   used  for  the  naming  of  this  group 
(Fig.  39). 

Fig.  41 


A,  bilateral  distoclusion  complicated  by  extreme  labioversion  of  the  upper  incisors; 
B,  bilateral  distoclusion  complicated  by  infraversion  of  the  upper  incisors. 


96  THE  DIAGNOSIS  OF  MALOCCLUSION 


SUMMARY 

In  confirming  the  diagnosis  of  a  malocclusion  we  proceed 
by  excluding  all  possible  conditions  in  the  order  of  their 
gravity.  Thus  dentofacial  deformity,  which  is  always 
serious,  is  first  considered.  Owing  to  the  fact  that  it  com- 
prises a  large  field  and  involves  many  grave  points,  it  was 
deemed  best  to  treat  it  separately  (Chapter  VI).  Next  in 
importance  comes  a  consideration  of  malformation  of  the 
jaws;  then  the  relation  of  the  arches,  or  the  totality  of  their 
alignment  and  occlusion;  then  the  occlusion  and  alignment 
of  each  tooth,  which  necessarily  implies  the  form  of  each 
arch;  and  such  other  anomalies  as  may  be  present. 

Finally,  the  naming  of  these  deformities  should  be  governed 
by  the  following  rules : 

1.  Jaw  deformities  so  extreme  as  to  be  beyond  the  scope 
of  orthodontic  treatment  should  receive  first  consideration. 
Their  accompanying  malocclusions  are  merely  symptoms. 

2.  Arch  malrelations  amenable  to  orthodontic  treatment 
are  next  in  importance. 

3.  All  cases  of  malocclusion  accompanied  by  a  neutral 
relation  of  the  arches  are  spoken  of  as  neutroclusions. 

4.  The  individual  peculiarities  of  any  given  case  are  best 
expressed  by  adding  such  qualifying  phrases  as  "compli- 
cated by  labioversion  of  the  upper  incisors,"  or  "  infraversion 
of  the  upper  incisors,"  etc.  (Figs.  40  and  41). 


CHAPTER   VI 

FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 
NORMAL  VARIATIONS  OF  THE  HEAD  FORM 

As  intimated  in  Chapter  I,  a  frequent  attribute  of  mal- 
occlusion is  a  marked  inharmony  of  the  facial  lines.  A 
rational  basis  for  conclusive  deductions  regarding  these 
deformities  is  a  knowledge  of  the  normal  variations  of 
facial  form.  To  a  large  extent  all  faces  are  similarly  formed, 
and  their  likenesses  are  patent  to  everyone;  yet  there  exist 
in  every  face  certain  lineaments  of  character  which  stamp 
it  with  individuality.  Indeed,  in  probably  no  other  part 
of  the  human  form  is  the  variability  of  features  so  evident. 

The  normal  variations  of  organic  beings  have  long  been 
a  subject  for  careful  study;  and  since  Darwin's  day  with 
renewed  earnestness.  It  remained  for  Blumenbach,^  Cam- 
per,2  and  Prichard^  to  first  draw  attention  to  the  relationship 
existing  between  the  teeth  and  their  osseous  base  and  the 
profile  or  facial  lines  of  man.  This  phase  of  scientific  inquiry 
now  forms  an  important  division  in  anthropology,  where,  in 
common  with  other  elaborate  systems  and  classifications,  it 
is  termed  anthropometry,  the  science  of  human  measure- 
ments. The  comparative  study  of  the  variable  morpho- 
logical aspects  of  the  skull  comprises  a  subdivision  termed 
craniometry.    When  the  measurements  are  made  upon  the 

1  Gottingen,  1775.  2  Berlin,  1792.  =  London,  1836. 

7 


98      FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

Fig.  42  Fia.  43 


Fig.  44 


Top  view  of  skulls:  Fig.  42,  negro,  index  70,  dolichocephalic.    Fig.  43,  European,  index 
80,  mesocephalic;  Fig.  44,  Samoyed,  index  85,  brachycephalic.    (After  Tyler.) 


NORMAL  VARIATIONS  OF  THE  HEAD  FORM       99 

living  head  it  is  termed  cephalometry.  Numerous  methods 
for  measuring  the  features  have  been  devised,  though  very 
few  have  been  sufficiently  standardized  to  win  universal 
acceptance.  Much  of  the  development  of  this  branch  of 
science  Ave  owe  to  the  French  anthropologist  Broca. 

Cephalic  Index. — In  comparing  a  number  of  skulls  even 
the  beginner  experiences  little  difficulty  in  detecting  differ- 
ences of  shape.  "  The  form  of  the  head  is  for  all  racial  pur- 
poses best  measured  by  what  is  technically  known  as  the 
cephalic  index.  This  is  simply  the  breadth  of  the  head  above 
the  ears  expressed  in  percentage  of  its  length  from  forehead 
to  back.  Assuming  that  this  breadth  is  100,  the  mdth  is 
expressed  as  a  fraction  of  it.  As  the  head  becomes  pro- 
portionately broader — that  is,  more  fully  rounded,  viewed 
from  the  top  down — this  cephalic  index  increases.  When 
it  rises  above  80,  the  head  is  called  br  achy  cephalic;  when 
it  falls  below  75,  the  term  dolichocephalic  is  applied  to  it. 
Indexes  between  75  and  80  are  characterized  as  7neso- 
cephalic."^  Figs.  42,  43,  and  44  are  diagrammatic  of  these 
variations  of  form. 

Other  Systems  of  Measurement. — Among  the  other  systems 
proposed  for  the  determination  of  differences  of  shape, 
mention  may  be  made  of  Camper's  method  for  the  measure- 
ment of  the  facial  angle  (Figs.  45  and  46),  Flower's  gnathic 
index,  and  Turner's  dental  index.^  By  means  of  the  gnathic 
index,  which  is  used  to  determine  the  amount  of  projection 
of  the  lewer  part  of  the  face,  the  races  of  mankind  may  be 
divided  into  three  groups,  as  follows:  Orthognathous,  when 
below  98;  mesognathous,  when  98.1   to   103;  prognathous. 


1  Ripley,  The  Races  of  Europe,  New  York,  1899. 

2  Tomes,  Dental  Anatomy,  5th  ed.,  p.  517. 


Fia.  45 


Fig.  46 


Camper's  measuremeDts  of  the  facial  angle. 


NORMAL   VARIATIONS  OF  THE  HEAD  FORM     101 

when  above  103.  With  the  dental  index  we  determine  "the 
relation  of  the  size  of  the  teeth  to  that  of  the  skull,"  and 
get  the  three  groups  termed  microdont,  index  42;  mesodont, 
index  43;  and  megadont,  index  44  and  above. 


Fig.  47 


B 


Normal  variation  of  the  s\iinphysian  angle. 
Fig.  48 


Noiraal  variation  of  the  symphysian  angle. 


Via.  49 


Normal  variation  of  the  symphysian  angle. 
Fig.  50 


C  4m  j  ^^'•f 


Normal  variations  of  alignment  of  the  upper  teeth.     (After  Broca.) 


Fia    51 


F"ia.  52 


Fig.  63 


Showing  variations  in  the  relative  position  of  the  lower  third  molar. 


104     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

Still  other  differences  of  interest  are  the  anthropological 
varieties  of  the  palate,  termed  by  Turner  dolichuranic, 
mesuranic,  and  hrachyuranic;  and  the  variations  due  to 
the  development  of  the  muscles  of  mastication.  The  latter 
are  readily  recognized  in  the  changeable  position  of  the 


Fig.  54 


Fig.  55 


Normal  variation  of  the  profile 
taken  from  life. 


Dental  model  of  the  case  shown  in  Fig.  54. 


temporal  ridge;  the  differences  in  width  of  the  ascending 
rami  of  Europeans  when  compared  with  the  aborigines;  the 
varying  degrees  of  parallelism  of  the  borders  of  the  rami;  and 
the  outward  and  inward  everted  angles  of  the  lower  jaw, 
which  affect  the  width  of  the  lower  part  of  the  face.  Other 
and  even  more  important  facts  of  interest  are  the  normal 


NORMAL  VARIATIONS  OF  THE  HEAD  FORM     105 

variations  of  the  symphysian  angle  (Figs.  47,  48,  and  49), 
and  the  ethnological  deviations  observed  by  Broca  in  the 
forms  of  the  dental  arches.  Of  the  latter  there  are  four 
varieties,  which  he  designated  parabolic,  hyperbolic,  ellip- 
tical, and  U-shaped  (Fig.  50). 


Fig.  56 


Fig.  57 


^^1 

tJ 

f 

.  '-:jL^.'iiVa#:%^:.ifc<ui' . 

IH 

Normal    variation  of    the 
profile  taken  from  life. 


Dental  model  of  the  case  shown  in  Fig.  56. 


A  still  further  evidence  of  variability  is  to  be  found  in 
the  relative  position  of  the  lower  third  molars.  Thus  in  the 
aborigines  it  usually  is  in  front  of  the  anterior  border  of  the 
coronoid  process,  while  in  the  Europeans  it  may  be  partly, 
or  entirely,  hidden  (Figs.  51,  52,  and  53).     The  teeth  and 


106     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

bones,  as  well  as  the  accessory  sinuses  of  the  nose,  differ 
also  in  their  size  and  form. 

Summary. — In  his  measurements  of  the  facial  lines.  Camper 
discovered  that  in  an  Australian  black  they  approached  an 
angle  of  85  degrees;  in  a  European,  95  degrees;  and  in  the 
beautiful  forms  of  Greek  art,  100  degrees  or  more.    This 


Fig.  58 


Fia.  59 


Normal   variation   of    the 
profile  taken  from  life. 


Dental  model  of  the  case  shown  in  Fig.  58. 


variation  is  largely  due  to  the  backward  sloping  of  the 
symphysis,  which  in  the  lower  races  approaches  the  chinless 
form  of  the  anthropoid  ape.  The  degree  of  prognathism,  or 
position  of  the  denture  in  its  relation  to  the  skull  as  a  whole, 
must  also  be  taken  into  consideration.  These  osseous  varia- 
tions affect  all  skulls  in  varying  degree,  and  in  Figs.  54,  56, 


NORMAL  VARIATIONS  OF  THE  HEAD  FORM     107 

and  58  we  see  three  photographs  which,  though  unlike  in 
general  contour,  are  normal  from  a  purely  orthodontic  stand- 
point. The  dental  models  of  these  three  profiles  are  shown  in 
Figs.  55,  57,  and  59,  and  it  will  be  seen  that  in  each  instance 
the  teeth  are  in  approximately  normal  occlusion. 


Fig.  60 


i 

i          .' 

^-Jg 

K 

^— ^H| 

hX*  ^JB^  z 

f~--l||E. 

:    ^ 

*"  ^^^HH^    — — *.-  ~— 

---i- 

— m 

Hi^             ~~ 

- — n- 

0- 

~—P' 

■ 

Showing  parts  of  the  face  of  special  interest  to  the  orthodontist :  a,  chin  (mentum); 
b,  aperture  (rima  oris);  c,  angle  {angulus  oris);  d,  philtrum;  e,  nostrils  (nares);  /,  ala 
{ala  nasi);  g,  dorsum  {dorsum  nasi);  h,  frontal  eminence;  i,  root  (radix  nasi);  j,  base 
{basis  nasi);  k,  tip  (apex  nasi);  I,  nasolabial  sulcus;  m,  cheek  (bucca);  n,  upper  lip; 
o,  lower  lip;  p,  mentolabial  sulcus. 

But  prior  to  a  consideration  of  the  effects  of  malocclusion 
upon  the  facial  lines  the  student  should  study  Fig.  60, 
which  represents  the  face  of  a  young  girl,  with  the  more 
important  parts  marked  in  the  area  which  is  so  frequently 


108      FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

affected  by  orthodontic  treatment.  Some  of  the  normal 
variations  in  the  arrangement  of  these  parts  have  been 
recognized  by  orthodontists. 

Fig.  61 


Neutroclusion  complicated  by  labioversion  of  the  upper  and  linguoversion  of  the 
lower  incisors.    (Compare  with  Fig.  62.) 


ABNORMAL  VARIATIONS  OF  THE  PROFILE 


The  various  anomahes  of  dentition  which  may  combine 
in  a  malocclusion  were  outlined  in  Chapter  V,  and  it  now 
becomes  necessary  to  describe  in  detail  the  deformities  of 
the  face  resulting  therefrom. 

In  Fig.  61  a  photograph  is  shown  of  a  dental  model 
exhibiting  a  pronounced  labioversion  of  the  upper  incisors. 
Obviously,  such  deformity  must  always  affect  the  contour 


ABNORMAL   VARIATIONS  OF  THE  PROFILE       109 

of  the  soft  and  yielding  tissues  of  the  Hps,  particularly  the 
upper.  It  will  be  observed  that  the  occlusion  of  the  first 
molars  is  normal,  there  being  no  arch  malrelation,  and  it  may, 
therefore,  be  classified  as  a  case  of  neutroclusion.  The  con- 
sequent distortion  of  the  facial  lines  is  shown  in  Fig.  62. 

A  similar  though  frequently  more]  pronounced  type  of 
deformity  is  shown  in  Fig.  63.    This  must  not  be  confused 

Fig.  62 


Facial  deformity  resulting  from  the  malocclusion  shown  in  Fig.  61. 


with  the  former,  however,  for  upon  closer  examination  it 
will  be  seen  that  though  we  again  have  a  labioversion  of 
the  upper  incisors,  there  exists  in  addition  a  bilateral  disto- 
clusion  of  the  lower  (Fig.  64).  Any  attempt  at  correction 
of  the  facial  deformity  and  of  the  labioversion  of  the  upper 
incisors  would  prove  futile  if  it  did  not  take  into  consider- 
ation the  distal  malrelation  of  the  lower  arch. 

Further  complications  in  these  types,  especially  in  patients 


110     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

beyond  the  developmental  period,  are  an  abnormal  growth 
of  the  lips,  an  arrest  of  development  in  the  alveolar  processes, 
and  malformations  of  the  jaws.     On  the  other  hand,  if 


Fig.  63 


Facial  deformity  resulting  from  tte  malocclusion  shown  in  Fig.  64. 
Fig.  64 


Bilateral  distoclusion  complicated  by  labioversion  of  the  upper  incisors. 
(Compare  -with  Fig.  63.) 


ABNORMAL   VARIATIONS  OF  THE  PROFILE       111 

correction  of  the  malocclusion  is  instituted  early,  a  restora- 
tion of  normal  function  and  subsequent  growth  of  the  bony 
structures  will  take  care  of  the  accompanying  inequalities 
of  facial  contour.  This  rarely,  if  ever,  follows  when  treat- 
ment is  too  long  postponed.  In  Fig.  65  a  profile  is  shown  of 
a  girl,  aged  sixteen  years,  with  such  a  deformity  completely 
established.  Suffering  from  mouth  breathing  for  a  number 
of  years,  the  upper  lip,  by  continual  stretching,  was  arrested 

Fig.  65 


Permanent  deformity  of  the  upper  lip  resulting  from  postponement  of  treatment 
of  the  malocclusion  shown  in  Fig.  66.     (Compare  Fig.  25.) 

in  its  development,  and  now  remains  too  short  and  too 
thin.  The  lower,  on  the  other  hand,  found  lodgement  in 
the  space  between  the  upper  and  lower  incisors,  and  thus, 
through  abnormal  function,  overdeveloped  (Fig.  66). 

The  reverse  of  this  type  of  deformity  is  found  in  neutro- 
clusions  complicated  by  a  linguoversion  of  the  upper  incisors; 
in  mesioclusions;   in  arrested  development  of  the  maxilla; 


112     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

Fig.  66 


Models  of  the  case  shown  in  Fig.  65. 


Fig.  67 


Facial  deformity  accompanying  the  malocclusion  shown  in  Fig.  68. 


ABNORMAL   VARIATIONS  OF  THE  PROFILE      113 

and  in  cases  of  macrognathism  of  the  mandible.  Figs.  67  and 
68  show  the  casts  and  photographs  of  a  lad,  aged  thirteen 
years,  where  the  lack  of  prominence  of  the  upper  lip  is 
very  apparent.  An  extreme  form  of  micrognathism  of  the 
maxilla,  with  distoclusion  of  the  upper  arch  and  infraversion 
of  the  anterior  teeth,  and  the  consequent  facial  deformity. 

Fig.  68 


Unilateral  mesioclusion,  resulting  in  deformity  of  the  profile  shown  in  Fig.  67. 


are  shown  in  Figs.  69  and  70.  Though  similar  to  the  former 
in  outward  appearance,  the  latter  must  not  be  considered 
as  belonging  to  the  same  group,  or  to  the  next  and  even 
more  serious  type  (Figs.  34  and  35).  The  latter  is  a  case  of 
mandibular  macrognathism,  of  which  the  accompanying 
mesioclusion  of  the  lower  arch  and  mesioversion  of  the  lower 
teeth   are   but    symptoms.      To   overlook   the    mandibular 


114     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

Fig.  69 


Maxillary  micrognathism. 


Fig.  70 


Profile  of  case  shown  in  Fig.  69. 


ABNORMAL   VARIATIONS  OF  THE  PROFILE      115 

deformity  in  such  a  case  is  to  utterly  fail  in  the  diagnosis. 
Indeed,  all  dentofacial  deformities,  of  whatever  type,  are 
but  symptoms  of  the  underlying,  and  therefore  more 
fundamental,  dental  anomalies. 

Fig.  71 


Deformity  due  to  curvature  of  the  mandible. 


The  so-called  "open  bite"  (Fig.  41,  B)  is  a  deformity 
commonly  associated  with  nasal  obstruction,  and  may  com- 
plicate either  neutroclusion,  mesioclusion,  or  distoclusion. 
Very  rarely  it  may  be  due  to  a  curvature  of  the  body  of 
the  mandible  (Fig.  71).  Attention  must  also  be  directed 
to  the  fact  that   in  the  unilateral    forms  of    distoclusion 


116      FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

and  mesioclusion  the  same  facial  deformities  may  exist  as 
in  the  bilateral  types,  though  they  are  usually  less  severe. 

Another  type  of  deformity  is  that  associated  with  supra- 
version  of  the  incisors,  which  may  be  symptomatic  of  neutro- 
clusion or  of  distoclusion;  and  in  all  of  these  the  outer  contour 
of  the  facial  muscles  involved,  particularly  of  the  lower  lip. 

Fig.  72 


Neutroclusion  aocompanied  by  the  facial  deformity  shown  in  Fig.  73 


appear  so  crowded  that  it  suggests  overdevelopment.  But 
this  is  usually  more  apparent  than  real,  because  after  the 
correction  of  the  malocclusion  they  readily  assume  a  normal 
form.  The  author  is  convinced,  moreover,  that  the  really 
seriQUs  condition  met  with  in  many  of  these  cases  is  a  lack 
of  perpendicular  development  in  the  region  of  the  symphysis. 
In  other  words,  the  distance  from  the  gingival  line  of  a  lower 


ABNORMAL   VARIATIONS  OF   THE  PROFILE      117 

central  incisor  to  the  mental  eminence  of  the  chin  is  too 
short.  This  condition  is  the  source  of  much  annoyance  to 
the  operator  during  treatment,  and  extremely  difficult  to 
permanently  correct. 

The  normal  variations  of  the  symphysian  angle  have 
already  been  referred  to.  Figs.  72  and  73  show  a  case  where, 
besides    exhibiting    considerable    malocclusion    of    a    type 

Fig.  73 


Showing  extreme  deficiency  of  the  symphysian  angle. 

ordinarily  demanding  a  liberal  expansion  of  both  the  upper 
and  lower  arches,  a  compromise  in  treatment  would  seem 
to  be  indicated.  The  receding  chin,  in  this  instance,  is  a 
fundamental  osseous  condition  wdiich  must  be  reckoned 
with,  and  which  no  amount  of  tooth  movement  at  this  late 
period  (the  patient  being  sixteen)  would  ever  correct. 


118     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 


ORTHODONTIC  CONCEPTIONS  AND  IDEALS 

The  mere  fact  that  orthodontics  embraces  methods  for 
the  correction  of  deformities  of  the  face  predicates  the 
desirabihty  of  a  standard,  or  criterion  of  judgment. 

Fig.  75 


Classical  profile  of  Apollo. 
(After  Farrar.) 


Measurements  employed  by  artists. 
(After  Wiegall.) 


"The  duties  of  the  orthodontist  force  upon  him  great 
responsibihties,  and  there  is  nothing  in  which  the  student 
of  orthodontia  should  be  more  keenly  interested  nor  better 
informed  than  in  the  study  of  the  artistic  proportions  and 
relations  of  the  features  of  the  human  face;  for  each  of 
his  efforts,  whether  he  realizes  it  or  not,  makes  for  beauty 
or  ugliness,  for  harmony  or,  inharmony,  for  perfection   or 


ORTHODONTIC  CONCEPTIONS  AND  IDEALS       119 

deformity."^  Furthermore,  besides  forming  an  important 
phase  of  the  difficult  art  of  diagnosis,  it  involves  us  in  "the 
most  remarkable  problem  of  esthetics,"  viz.,  that  of  beauty 
of  form.  Ignorance  of  these  requirements  has  led  numerous 
operators  into  the  unenviable  position  of  having  permanently 
marred  the  beauty  of  an  otherwise  handsome  face. 

In  the  works  of  Kingsley,  Farrar,  Jackson,  etc.,  the  need 
for  some  standard  as  an  aid  in  diagnosis  was  plainly  felt. 
The  classical  profile  of  the  Grecian  mythological  god 
Apollo  (Fig.  74)  and  the  lines  of  division  employed  by 
artists  in  the  study  of  esthetics  (Fig.  75)  have  been  widely 
used  for  this  purpose.  But  not  until  Case^  and  Angle^ 
developed  their  comprehensive  systems  did  we  approach 
methods  of  tolerable  accuracy.  Unfortunately,  a  review  of 
the  works  of  these  two  authors  reveals  the  fact  that  their 
conclusions  are  diametrically  opposed  to  each  other. 

Case's  Ideal. — A  large  experience  and  much  careful  obser- 
vation have  led  Professor  Case  to  formulate  the  following 
principles : 

"The  portion  of  the  human  face  that  it  is  possible  to 
change  with  dental  regulating  apparatus  may  be  said  to  lie 
between  two  diverging  lines  which  arise  at  a  point  below  the 
ridge  of  the  nose  and  curve  downward  to  enclose  the  alse 
and  depressions  on  either  side;  thence  laterally  to  encircle 
a  portion  of  the  cheek,  and  downward  to  enclose  the  entire 
chin  (Fig.  76).  This  area  may  be  termed  the  changeable 
area  in  contradistinction  t^^he  more  stable  features,  or 
unchangeable  area.  For  convenience  of  ready  reference,  the 
features  in  that  portion  of  the  changeable  area  which  are 

1  Angle,  Amer.  Text-book  of  Oper.  Dentistry,  3d  ed.,  p.  694. 

2  Dental  Orthopedia,  1908. 

5  Malocclusion  of  the  Teeth,  7th  ed.,  1907. 


120      FACIAL  DEFORMITIES  DUE   TO  MALOCCLUSION 

bounded  laterally  by  the  nasolabial  lines  may  be  divided 
into  four  segments,  as  follows : 

"Segment  1.  The  end  of  the  nose  and  the  upper  portion 
of  the  upper  lip,  including  the  nasolabial  depressions. 

"Segment  2.  The  lower  portion  of  the  upper  lip. 

"Segment  3.  The  lower  lip. 

"Segment  4.  The  chin. 

"These  four  segments  are  changeable  in  their  relations 
to  each  other,  and  also  in  their  individual  relation  to 
features  in  the  unchangeable  area." 

Fig.  76 


Unchangeable  area 


Changeable  area  "I 


Method  of  measurement.     (After  Case.) 


Dr.  Case  further  maintains  that  the  relations  of  these 
areas  to  each  other  must  be  determined  prior  to  treatment 
by  the  trained  eye  of  the  operator,  and  the  deviations,  if  any, 
noted.  Following  this  the  treatment  must  be  planned  so 
as  to  produce  the  best  possible  exterior  effects  or  contour 
of  these  parts.    In  other  words,  the  operator's  ideal  of  facial 


ORTHODONTIC  CONCEPTIONS  AND  IDEALS      121 

form  is  the  standard  or  criterion  he  would  ha\e  accepted. 
It  is  presumed,  of  course,  that  this  be  a  cultivated  ideal, 
carrying  with  it  that  fine  discretionary  ability  to  say  when 
teeth  shall  be  extracted,  or  moved  bodily,  for  the  improve- 
ment of  facial  balance.  According  to  this  author,  the  full 
complement  of  teeth  is  not  necessary  in  the  treatment  of 
certain  types  of  malocclusion;  in  some  instances  extraction 
of  one  or  more  teeth  is  positively  indicated. 

Fig.  77 


Shows  the  unrelatedness  of  beauty  of  form  and  beauty  of  elements. 
(After  Santayana.) 


Theoretically,  this  is  perhaps  true,  because  "Beauty  of 
form  cannot  be  reduced  to  beauty  of  elements.  All  marble 
houses  are  not  equally  beautiful."  Similarly,  all  profiles, 
even  though  they  are  moulded  over  an  ideal  occlusion  of 
all  the  permanent  teeth,  are  not  equally  beautiful.  "All 
ideal  forms  have  an  emotional  tinge.  Beauty  of  form  is  due 
to  expression,  and  all  expression,  ultimately,  is  something 
else  than  beauty — some  practical  or  moral  good."  For 
example,  "take  the  ten  meaningless  short  lines  in  Fig.  77, 


122     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

and  arrange  them  in  the  given  ways  intended  to  represent 
the  human  face;  there  appear  at  once  notable  different 
esthetic  values.  Two  of  the  forms  are  differently  grotesque, 
and  one  approximately  beautiful.  These  effects  are  due  to 
the  expression  of  the  lines;  not  only  because  they  make  one 
think  of  fair  or  ugly  faces,  but  because,  it  may  be  said,  these 
faces  would  in  realit}^  be  fair  or  ugly  according  to  their 
expression,  according  to  the  vital  and  moral  associations  of 
the  different  types. "^ 

Angle's  Ideal. — But  according  to  Angle,  "We  must  be  able 
to  detect  whether  the  features — that  is,  the  forehead,  the 
nose,  the  chin,  the  lips — of  each  individual  face  balance, 
harmonize,  or  whether  they  are  out  of  balance,  out  of  har- 
mony, and  especially  whether  the  mouth  is  in  harmonious 
relations  with  the  other  features,  and  if  it  is  not,  what  is 
necessary  to  place  it  in  balance.  The  faculty  of  determin- 
ing the  proper  balance  of  the  features  is  a  difficult  one  to 
attain."  Quoting  Prof essor  Wuerpel,  he  further  says :  "Only 
one  in  two  or  three  hundred  art  students  ever  succeed  in 
mastering  it,  and  these  only  after  much  observation  and 
practice  in  sketching  and  modelling  of  faces.  Unpromising 
as  this  seems,  it  is  doubtless  correct;  yet  we  have  a  rule  for 
determining  the  best  balance  of  the  features,  or,  at  least, 
the  best  balance  of  the  mouth  with  the  rest  of  the  features, 
that  artists  probably  know  nothing  of,  and  one  that  for  the 
orthodontist  is  more  unvarying  and  more  reliable  than  even 
the  judgment  of  the  favored  few — a  rule  so  invariable  and 
with  so  few  exceptions  that  we  may  consider  it  a  law,  and 
if  it  be  not  applicable  in  all  cases,  the  exceptions  will  be 
so  very  rare  that  they  are  hardly  worth  considering.     It  is, 

1  Santayana,  The  Sense  of  Beauty. 


ORTHODONTIC  CONCEPTIONS  AND  IDEALS      123 


Fig.  7S 


Shows  the  aiitlior'a  method  for  estimating  in  advance  the  probable  effet-t 
of  an  orthodontic  treatment.    (Compare  with  Fig.  79.) 


124     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 


furthermore,  a  rule  so  plain  and  so  simple  that  all  can  under- 
stand and  apply  it.  It  is  thai  the  best  balance,  the  best  harmony, 
the  best  proportions  of  the  mouth,  in  its  relations  to  the  other 
features,  require  thai  there  shall  be  the  full  complement  of  teeth, 
and  that  each  tooth  shall  be  made  to  occupy  its  normal  position 
— normal  occlusion." 

Fig.  79 


Photographs  of  the  patient  before  and  after  the  use  of  the  wax  mould 
shown  in  Fig.  78. 

Expressed  differently,  Angle  maintains  that  the  outward 
form  of  the  changeable  area  of  the  face  is  dependent  upon 
the  relative  normality  of  the  denture  within;  and  that,  as  a 
rule,  it  is  best  to  establish  normal  occlusion  (which  implies 
the  presence  of  each  tooth),  and  thus  strike  a  balance  which 
is  rarely  wrong.  Theoretically,  this  is  not  absolutely  true; 
and  it  can  hardly  be  called  a  law,  using  the  word  in  its 
scientific  sense.  But  many  operators  of  wide  experience  are 
practically  unanimous  in  support  of  his  contention,  hence  it 


ORTHODONTIC  CONCEPTIONS  AND  IDEALS       125 

has  become  a  fundamental  postulate  in  orthopedic  practice. 
In  other  words,  it  is  true  because  it  ought  to  be  true,  and 
because  the  opposite  practice  of  sacrificing  teeth  for  the 


Fia.  80 


Method  employed  in  distoclusiona.    (Compare  with  Fig.  81.) 


126      FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

improvement  of  facial  contour  is  rarely  necessary,  and 
seldom  advantageous.  Indeed,  the  necessity  for  the  extrac- 
tion of  one  or  more  teeth  is  so  infrequent  that  its  practice 
has  become  almost  obsolete.  This  is  particularly  true  in  all 
cases  where  the  treatment  is  instituted  during  the  develop- 
mental period.  The  development  of  the  surrounding  osseous 
structures  subsequent  to  tooth  movement  is  usually  to  be 
expected  in  young  patients;  hence  their  profile  must  never 
be  considered  as  a  fixed  line  (at  least  not  immediately  after 
treatment),  but  one  in  which  further  changes  will  continue 
to  take  place. 

Fig.  81 


Shows  temporary  effect  upon  the  profile. 


DIAGNOSTIC  METHODS 


In  order  to  ascertain  in  advance  the  probable  effect  of 
treatment  upon  the  facial  lines,  the  author  has  used  the 
following  methods  whenever  ap])licable: 


DIAGNOSTIC  METHODS 


127 


In  cases  of  neutroclusion  accompanied  by  linguoversion 
of  the  incisors,  a  piece  of  softened  wax  is  moulded  over  the 


Fig.  82 


Same  method  as  in  Fig.  80. 


128     FACIAL  DEFORMITIES  DUE  TO  MALOCCLUSION 

occluded  models  and  trimmed  to  a  form  approaching  the 
future  alignment  of  these  teeth  (Fig.  78).  After  it  has 
been  allowed  to  cool  it  is  placed  in  position  in  the  mouth. 
The  patient  is  now  asked  to  relax  all  tension  of  the  lip 
muscles,  which  allows  the  facial  lines  to  assume  the  form 
which  the  treatment  will  ultimately  produce  (Fig.  79). 

FiQ.  83 


Photographs  of  case  shown  in  Fig.  82. 


In  distoclusion  accompanied  by  labio version  of  the 
upper  incisors  (Fig.  80,  a)  the  patient  is  requested  to  bite 
mesially,  so  as  to  bring  the  first  molars  into  normal  mesio- 
distal  relations.  Fig.  81  clearly  shows  the  effect  upon  the 
facial  lines,  representing  photographs  of  the  patient  with 
the  teeth  in  the  positions  shown  in  Fig.  80,  a  and  b.  Simi- 
lar preliminary  studies  can  be  made  of  patients  presenting 
a  distoclusion  accompanied  by  linguoversion  of  the  upper 
incisors.     The  latter  type  frequently  combines  with  supra- 


DIAGNOSTIC  METHODS  129 

version  of  the  incisors  and  infraversion  of  the  molars  and 
bicuspids,  for  which  Dr.  Case^  has  suggested  a  temporary 
"opening  of  the  bite."  If  necessary,  pieces  of  modelling 
compound,  or  wax,  are  previously  inserted  to  prevent 
complete  closure,  and  while  in  this  position  a  study  of 
the  profile  can  be  made  (Figs.  82  and  83). 

In  the  more  serious  cases  of  facial  deformity,  e.  g.,  those 
due  to  mandibular  macrognathism  or  to  infraversion  of  the 
incisors,  these  methods  are  inapplicable. 

1  Dental  Orthopedia,  p.  323, 


CHAPTER   VII 

THE  PROGNOSIS  OF  MALOCCLUSION 

DEFINITION 

The  medical  term  prognosis  is  used  to  denote  the  probable 
result  of,  or  prospective  recovery  from,  a  disease  or  abnor- 
mality. It  is  an  opinion  concerning  the  duration,  course, 
and  termination  of  a  disease  and  of  the  outcome  of  the 
treatment.  And  while  such  judgments  necessarily  vary  in 
accordance  with  an  operator's  experience,  they  are,  never- 
theless, dependent  upon  conditions  inherent  in  each  case. 

In  orthodontic  practice  it  frequently  becomes  necessary  to 
render  an  intelligent  opinion  in  advance  of  treatment;  and 
it  is  well  to  remember  that  a  favorable  prognosis  depends 
largely  upon  an  early  diagnosis,  when  conditions  are  such 
that  a  comparatively  simple  treatment  will  suffice.  For- 
merly it  was  customary  to  postpone  most  treatments  until 
all  of  the  permanent  teeth  had  erupted,  for  it  was  believed 
that  nature  would  assist  in  the  correction  of  the  malocclusion, 
and  that  most  patients  would  "outgrow"  the  deformity. 
Many  bitter  disappointments  have  taught  us  the  error  of 
such  advice,  and  strongly  emphasize  the  fact  that  the  severe 
forms  of  malocclusion  do  not  develop  over  night,  but  are  of 
slow  growth.  Hence  it  follows  that  years  before  even  an 
intelligent  parent  recognizes  the  impending  deformity,  the 
alert  diagnostician  can  advise  ways  and  means  for  its 
prevention. 


GENERAL  CONSIDERATIONS  131 


GENERAL  CONSmERATIONS 

Age  and  Health. — Age  and  health  may  be  regarded  as  funda- 
mental considerations  in  every  prognosis.  Thus  a  macrog- 
nathic  mandible,  accompanied  by  mesioclusion  of  the  lower 
arch,  might  readily  yield  to  treatment  between  the  eighth 
and  tenth  years.  On  the  other  hand,  if  such  a  condition  is 
neglected  until  the  twentieth  year  the  deformity  might  then 
be  so  severe  that  orthodontic  measures  for  its  correction 
would  prove  futile.  Similarly,  if  treatment  is  attempted  in 
two  cases  of  the  same  age  and  type,  but  with  widely  divergent 
conditions  of  general  and  oral  health,  their  response  to  treat- 
ment might  vary  considerably.  Let  us  suppose  that  in 
one  case  immunity  to  caries  had  always  existed;  that  the 
patient's  robust  health  permits  the  operator  to  carry  the 
treatment  to  a  rapid  and  successful  conclusion.  In  the 
other,  we  find  caries  very  progressive,  and  the  oral  secretions 
markedly  abnormal;  the  patient  is  hypersensitive  and 
enfeebled  by  prolonged  illness.  It  is  obvious  that  in  the 
latter,  response  to  treatment  will  be  extremely  slow  or 
plainly  doubtful,  even  though  it  be  administered  by  the 
same  experienced  hands.  To  be  able  to  detect  such  differ- 
ences in  advance  is  often  difficult,  and  the  ability  to  do  so 
can  only  be  acquired  by  a  wide  experience  and  much  careful 
observation. 

Sex. — Dr.  Guilford^  has  pointed  out  that  the  question  of 
sex  may  enter  into  a  prognosis,  and  claims  that  "a  robust 
boy  can  undergo  an  operation  that  in  a  tender  girl  might 
result  in  nervous  shock  or  even  greater  physical  harm." 
He  rightly  maintains  that  a  "loss  of  general  health  could 

'  Orthodontia,  4th  ed.,  p.  41, 


132  THE  PROGNOSIS  OF  MALOCCLUSION 

never  compensate  for  an  improvement  of  the  dental  organs, 
however  great."  Other  writers  assert  that  sex  is  of  httle 
consequence,  and  they  are  unwilHng  to  accept  a  comparison 
between  a  "robust  boy"  and  a  "tender  girl,"  because  there 
are  many  robust  girls  who  make  better  patients  than  tender 
boys.  However,  it  appears  self-evident  that  the  advent 
of  puberty  in  females,  with  its  frequent  disturbances  of 
bodily  equilibrium,  requires  the  exercise  of  more  than 
ordinary  care  and  attention;  all  of  which  emphasizes  the 
necessity  for  early  treatment. 

Furthermore,  the  methods  of  today  are  such  that,  when 
properly  administered,  they  do  not  act  as  a  hardship  on  the 
patient.  It  is  unfortunate,  therefore,  that  the  cry  of  an 
ignorant  laity  should  raise  an  echo  in  the  profession,  leading 
to  a  denunciation  of  orthodontics,  and  the  claim  that  its 
treatments  seriously  undermine  the  health  of  many  indi- 
viduals. Dr.  Ketcham^  and  others  have  gathered  data  in 
refutation  of  these  false  assertions,  and  have  found  that 
practically  all  patients  gained  in  weight  during  the  entire 
period  of  orthodontic  treatment;  many  of  them  improved 
rapidly  in  their  studies  at  school,  and  few  failed  to  respond 
favorably  to  treatment.  This  ought  not  to  cause  surprise 
when  we  consider  that  most  parents  are  sufficiently  careful 
not  to  demand  orthodontic  services  for  their  sick  children. 

A  well-meant,  though  misdirected,  enthusiasm  has 
prompted  some  operators  to  ignore  entirely  the  factors  of 
age  and  sex,  and  to  accept  cases  of  advanced  years.  Most 
of  these  patients  are  women  who  suddenly  desire  amends 
in  facial  expression,  but  with  expectations  entirely  beyond 
the  achievable.     Though  a  carefully  executed  orthodontic 

1  Dental  Cosmos,  September,  1910. 


SPECIAL  CONSIDERATIONS  133 

operation  usually  improves  the  facial  lines,  there  are  many 
instances  where  the  results  could  hardly  be  called  beautiful, 
and  for  which  the  operator  is  in  no  wise  responsible.  Let 
the  beginner  beware,  therefore,  of  all  mature  cases  with  a 
doubtful  prognosis;  especially  in  the  cases  of  married  women, 
with  the  ever-present  possibility  of  an  intervening  preg- 
nancy. The  latter  constitutes  an  exceedingly  unfavorable 
condition,  rendering  post-treatment  maintenance  extremely 
doubtful,  if  not  impossible. 


SPECIAL  CONSIDERATIONS 

One  of  the  most  important  factors  entering  into  a  prognosis 
is  that  of  cause,  the  ignoring  of  which  has  led  to  many 
failures.  The  removal  of  the  cause,  whenever  possible,  is 
the  first  step  in  successful  treatment.  Of  course,  in  a  great 
many  instances  (owing  to  our  limited  knowledge  of  this 
subject)  we  are  unable  to  proceed  in  this  manner;  but  this 
makes  it  all  the  more  imperative  to  do  so  in  all  cases  where 
the  cause  is  readily  recognized.  By  way  of  illustration,  let 
us  consider  the  case  shown  in  Figs.  84  and  85,  exhibiting 
abnormal  breathing.  This  symptom  connotes  nasal  obstruc- 
tion, which  usually  stands  in  causal  relation  to  the  mal- 
occlusion. Its  presence  and  neglect  in  early  childhood 
invariably  leads  to  malocclusion  of  the  permanent  teeth, 
and  in  all  cases  associated  with  mouth  breathing  the  com- 
petent treatment  of  the  abnormal  nasal  conditions  should 
be  insisted  upon.  (Compare  with  Fig.  4:1,  A,  which  is  from 
a  patient  of  similar  type  at  the  age  of  sixteen.) 

Owing  to  the  mechanical  aspects  of  dentition,  the  self- 
correction  of  most  forms  of  malocclusion  is  an  impossibility. 


134  THE  PROGNOSIS  OF  MALOCCLUSION 

Fig.  84 


Facial  deformity  in  a  lad  of  eight  years  suffering  from  nasal  obstruction. 
Fig.  85 


Denture  of  case  shown  in  Fig.  84. 


SPECIAL  CONSIDERATIONS 


135 


Nature  and  time  rarely  exercise  a  corrective  influence  upon 
them.  To  the  usual  c^uestions,  then,  which  parents  so 
frequently  ask  in  first  consultation,  a  negative  answer  is 
uniformly  best.  The  accompanying  facial  deformities,  which 
are  often  the  immediate  reason  for  their  inquiries,  grow 
steadily  worse.     Fig.  86  shows  the  models  of  a  lad,  aged 

Fia.  86 


Incipient  unilateral  distoclusion  at  eighth  year. 


eight  years,  whose  parents  found  it  convenient  to  heed  the 
advise  of  an  ignorant  dentist:  "  He'll  outgrow  that  in  a  few 
years.  I  wouldn't  advise  any  treatment  now."  These  and 
many  similar  assertions  are  soothing  to  a  father's  purse. 
During  the  few  minutes  this  boy  occupied  the  author's 
operating  chair,  and  while  his  remarks  on  the  urgent  neces- 
sity for  treatment  were  slowly  and  emphatically  expressed. 


FiQ.  87 


Same  case  as  Fig.  86  at  age  of  fourteen. 
Fig.  88 


Facial  deformity  accompanying  case  shown  in  Fig.  87. 


SPECIAL  CONSIDERATIONS  137 

the  impressions  from  which  these  models  were  made  were 
taken.  Under  pressure,  probably,  of  the  conflicting  social 
and  economic  tendencies  of  our  age,  this  lad  and  his  parent 
disappeared  from  the  immediate  scene.  Six  years  elapsed 
before  their  return,  during  which  time  the  models  rested 
peacefully  in  their  place  in  the  cabinet.  x4nother  dentist  is 
now  caring  for  this  family's  dental  ills,  and  their  return  to 
the  author's  office  is  not  an  unusual  or  unexpected  incident. 
Fig.  87  shows  the  same  denture  at  the  age  of  fourteen,  and 
Fig.  88  the  pronounced  deformity  of  the  face  which  time 
and  nature,  unaided,  had  wrought.  The  history  of  many 
similar  maldevelopments  could  here  be  introduced;  they  are 
all  too  common,  even  in  this  day.  But  multiplication  is 
unnecessary.  Every  fact  gleaned  from  a  study  of  the  process 
of  dentition  substantiates  the  orthodontic  axiom  that  mal- 
occlusion and  its  accompanying  deformities  are  yrogressive, 
not  static.  In  short,  the  prognosis  of  malocclusion  is  equally 
as  unfavorable  as  of  caries  of  the  enamel;  the  evil  conse- 
quences are  equally  certain.  The  old  adage,  "An  ounce  of 
prevention,  etc.,"  is  decidedly  apropos  in  a  consideration 
of  malocclusion  of  the  teeth. 

The  one  great  lesson,  then,  which  recent  orthodontic 
progress  teaches  is  that  all  forms  of  malocclusion  develop 
slowly;  that  during  childhood  they  are  ever  in  process  of 
development.  To  appreciate  this  evolution  of  types,  to 
detect  them  in  their  incipiency,  and  to  divert  the  underlying 
forces  into  channels  of  normality — this  is  the  highest  mission 
of  orthodontics.  But  there  is  another  lesson  which  must  be 
more  widely  taught  than  formerly,  and  which  has  been  too 
much  neglected,  namely,  the  important  relation  a  normal 
denture  bears  to  health.  In  earlier  periods  orthodontic 
efforts  were  appreciated   mainly  for  their  esthetic  conse- 


138  THE  PROGNOSIS  OF  MALOCCLUSION 

quences;  the  desire  for  an  improvement  of  facial  harmony 
was  the  prime  motive  in  most  instances.  More  recently 
we  have  come  to  a  realization  of  the  fact  that  a  normal 
denture  implies  normal  occlusion,  without  which  its  efficiency 
is  greatly  reduced. 

The  recent  experiences  of  many  practitioners  have  led  us 
to  a  keener  appreciation  of  the  "golden  age  for  treatment," 
by  which  we  mean  that  time  in  an  individual's  life  when  the 
change  from  the  temporary  to  permanent  dentition  takes 
place.  This  covers  the  period  from  the  sixth  to  the  four- 
teenth year.  In  rare  instances  (those  cases  which  early 
exhibit  a  tendency  toward  extreme  malformation  of  the 
jaws)  it  has  been  found  advisable  to  begin  treatment  prior 
to  the  sixth  year.  And  in  most  cases  of  mesioclusion  or  disto- 
clusion  it  is  best  to  institute  treatment  as  soon  as  it  can  be 
diagnosed,  i.  e.,  immediately  after  the  eruption  of  the  four 
first  permanent  molars. 

The  establishment  of  the  alveoli  and  the  complete  cal- 
cification of  the  roots  of  the  teeth;  the  development  of 
the  temporomandibular  articulation;  the  lengthening  of  the 
rami  and  the  development  of  the  body  of  the  mandible — ■ 
all  these  are  considerations  which  must  be  reckoned  with. 


CLINICAL  SUMMARY 

A  brief  study  of  the  various  forms  readily  establishes  the 
conclusion  that  in  their  earliest  stages  all  are  comparatively 
simple.  Figs.  89  and  90  show  two  cases  of  distoclusion; 
one  aged  nine  years,  the  other  fourteen.  In  Fig.  89  it  will 
be  noticed  how  the  linguoversion  of  the  upper  central 
incisors  prevents  a  normal  mesiodistal  relation  of  the  lower 


Fig.  89 


Incipient  bilateral  distoclusion  at  nine  years. 
Fig.  90 


Same  type  of  malocclusion  at  fourteen  years. 


140 


THE  PROGNOSIS  OF  MALOCCLUSION 


arch;  the  tendency  is  toward  an  arrest  of  development  of 
the  mandible.  Note  further  how  the  molars  are  thereby 
prevented  from  coming  into  normal  occlusion.  A  moment's 
comparison  establishes  the  inference  that  the  older  case 
(Fig,  90)  passed  through  a  similar  stage. 

Fig.  91 


Bilateral  mesioclusion  at  eleven  years. 


That  the  history  of  mesioclusion  is  similar  is  equally 
certain  is  shown  by  a  comparison  of  models  in  Figs.  91  and 
92.  Fig.  91  is  made  from  the  denture  of  a  boy,  aged  eleven 
years,  while  Fig.  92  is  from  an  adult,  aged  twenty-eight 
years.  It  is  inconceivable  how  neglect  could  prove  beneficial 
to  Fig.  91;  it  is  the  surest  way  toward  a  multiphcation  of 
difficulties.     If  the  influences  of  abnormal  function,  of  the 


CLINICAL  SUMMARY  141 

impacts  during  use,  are  considered,  it  becomes  evident  that 
the  omission  of  treatment  constitutes  a  "penny-wise  and 
pound-foolish  policy."  How  an  intelligent  dentist,  intrusted 
with  the  care  of  the  mouths  of  growing  children,  could  permit 
such  abnormal  developments  under  his  very  eyes  and  not 
remonstrate  against  them  is  incomprehensible.    The  probable 

Fig.  92 


Mandibular  macrognathism  at  twenty-eight  years. 

result  of  treatment  for  Fig.  91  is  exceedingly  favorable;  the 
correction  of  the  mandibular  macrognathism  of  Fig.  92 
lies  beyond  the  domain  of  orthodontics.  (See  Chapter 
XVIII.) 

In  the  next  illustration  (Fig.  93)  we  note  a  distoversion 
of  the  upper  centrals  in  a  girl,  aged  eight  years,  due  to  an 


142 


THE  PROGNOSIS  OF  MALOCCLUSION 


abnormal  frenum  labium,  and  another  (Fig.  94)  at  the 
age  of  twelve.  Four  years  of  neglect  have  again  demon- 
strated their  evil  consequences.    The  diastema  between  the 


Fig.  93 


Denture  of  a  girl,  aged  eight  years. 
Fia.  94 


^^ 

0 ,  wim»       ^^^^1 

W''^ 

mp^ 

Hitf 

^^jgl^ 

Similar  type  at  the  age  of  twelve, 


CLINICAL  SUMMARY  143 

centrals  caused  an  encroachment  upon  the  lateral  spaces, 
and  when  the  latter  finally  appeared  they  readily  erupted 
lingual  to  normal.  A  further  study  of  many  similar  cases 
might  here  be  introduced,  but  the  lesson  from  each  would 
be  substantially  the  same.  To  the  question  then.  Is  early 
treatment  always  advisable?  the  uniform  reply  is  Yes. 
Should  postponement  of  treatment  be  desirable  in  a  given 
case,  the  operator  should  be  accorded  the  privilege  of  the 
decision. 

As  to  treatment,  MacDowelP  has  suggested  a  classification 
of  cases  into  three  groups,  as  follows: 

The  possible:  all  cases  between  the  ages  of  eight  and 
fourteen. 

The  probable:  mesioclusions  and  distoclusions  after  the 
age  of  fourteen. 

The  impossible:  most  cases  beyond  the  age  of  sixteen. 

Skilful  orthodontists  regard  this  as  a  very  conservative 
classification,  because  a  wide  experience  enables  them  to 
considerably  extend  the  age  limit  of  each  group.  But  the 
beginner  will  find  it  a  valuable  guide,  it  being  the  part  of 
wisdom  to  err  on  the  side  of  safety. 

1  Orthodontia,. xvii. 


CHAPTER  VIII 

THE  EVOLUTION  OF  METHODS 
METHODS  OF  THE  PAST 

Scientific  progress  during  the  last  half  century  has  so 
altered  our  conceptions  regarding  the  theory  of  life  and  the 
growth  of  society,  that  we  are  forced  to  re-write  history 
and  adapt  it  to  the  evolutionary  philosophy  (Pearson^). 
Present-day  standards  require  history  to  be  more  than 
antiquarian;  the  real  profit  in  tracing  the  development  of 
an  art  must  rest  in  something  else  than  a  mere  knowledge 
of  what  has  happened  in  chronological  order;  it  must  dwell 
in  an  understanding  of  the  principles  that  have  promoted 
the  developments  of  the  past,  in  the  meaning  of  certain 
events.  This  advance  in  our  conceptions  is  due  to  the 
epoch-making  labors  of  Darwin,  "who  made  all  reasoning 
since  his  day  follow  his  method." 

Now,  in  tracing  the  evolution  of  orthodontics  the  aim 
should  be  to  view  its  development  from  the  standpoint  of 
this  new  and  higher  perspective.  In  no  other  division  of  its 
subject  matter  is  this  more  desirable  than  in  the  methods 
of  treatment.  Not  that  the  tracing  of  its  remedial  measures 
constitutes  the  whole  of  its  history;  the  evolution  of  the 
science  and  the  history  of  its  theoretical  foundations  are 
equally  important.     But  a  greater  unanimity  of  opinion 

1  The  Grammar  of  Science. 


METHODS  OF  THE  PAST  145 

regarding  these  fundamentals  has  always  existed.  Indeed, 
the  principles  of  the  science  are  readily  traced;  in  these 
fields  a  greater  harmony  prevails  than  a  first  survey  seems  to 
justify.  Not  so  with  the  art.  The  steep  aclivity  up  which 
we  have  so  slowly  traveled  measures  a  progress  not  without 
interest  or  strife.  The  desire  for  supremacy  on  the  part 
of  several  of  our  leaders  has  added  its  bitterness  as  well  as 
charm. 

The  delineation  of  the  methods  of  treatment  is  difiicult 
not  only  because  they  have  been  as  varied  as  could  well  be 
imagined,  but  because  they  comprise  an  overwhelming  mass 
of  trivial  details.  Formerly,  the  dentist  only  occasionally 
dabbled  in  matters  orthodontic,  and  thus  failed  to  grasp 
the  principles  underlying  the  technical  details  of  treatment. 
Prior  to  diagnostic  systems  each  case  constituted  a  class 
by  itself,  so  that  the  designing  and  constructing  of  a  mechan- 
ism for  treatment  often  taxed  to  the  utmost  the  inventive 
capacities  of  the  practitioner.  Thus  the  birth  of  the  new 
order  was  painfully  prolonged,  and  the  rudiments  of  present- 
day  methods  unwittingly  obscured. 

But  in  1878  Dr.  Farrar,  of  New  York  (see  page  27), 
prophesied  lines  of  advance  which  have  since  been  followed 
with  increasing  advantage  and  favor.  The  import  of  his 
prediction  was  not  readily  grasped,  though  it  stipulated 
the  standardization  of  appliances  and  their  being  carried  in 
stock  by  dealers.  Indeed,  this  ideal  is  not  yet  fully  achieved, 
though  its  influence  thus  far  has  been  nothing  short  of 
revolutionary.  It  has  forever  relegated  appliance  manufac- 
ture where  it  rightfully  belongs,  has  freed  the  mind  of  the 
operator  of  many  petty  details,  and  furnished  the  necessary 
leisure  for  the  investigation  of  more  important  matters. 
Viewed  in  this  wise,  it  is  not  difficult  to  imagine  the 
10 


146 


THE  EVOLUTION  OF  METHODS 


probable   present   status   of   a   department   like   operative 
dentistry  had  not  the  manufacturer  long  ago  come  to  the 


Fig.  95 


Fauchard's  metallic  alignment  band  (1728).    (After  Pfa£E.) 
Fig.  96 


Schange's  appliance  (1840).     (After  Pfaff.) 

rescue.     The  wonder  of  it,  then,  is  not  how  little,  but  how 
much  the  past  has  achieved.    Truly,  a  sincere  review  of  the 


METHODS  OF  THE  PAST 


u: 


work  of  the  pioneers  and  pathfinders  awakens  the  deepest 
reverence;  their  labors  must  ever  be  regarded  as  indispen- 
sable stepping  stones.  Though  they  are  now^  fading  from 
twilight  into  dusk,  let  us  not  forget  that  they  ushered  in 
that  golden  dawn  which  made  the  present  possible. 

F'ig.  95  shows  an  appliance  used  by  Fauchard  (1728),  and 
exhibits  the  principle  of  our  present-day  alignment  wire. 
Fig.  96  shows  an  appliance  designed  by  Schange  (1840),  and 
embodies  the  essentials  of  mechanisms  in  use  today.     A 


Fig.  97 


Flagg's  round  alignment  wire  (1865).     (After  Pfaff.) 


similar,  though  greatly  simplified,  apparatus  is  shown  in 
Fig.  97,  being  a  design  by  Flagg  (1865).  It  represents  the 
round  alignment  wire,  with  flattened  ends  anchored  to  the 
molars,  and  serves  as  a  goal  toward  which  the  malposed 
teeth  are  moved  by  means  of  ligatures.  A  comparative 
study  of  other  elements  might  easily  be  here  introduced, 
though  a  sufficient  number  have  been  shown  to  demonstrate 
their  gradual  evolution.  Some  systematists  have  studiously 
avoided  such  comparative  study,  and  utilized  well-chosen 
contrasts  to  their  own  advantage. 


148 


THE  EVOLUTION  OF  METHODS 


RISE  OF  THE  SYSTEMS 

Following  the  epoch-making  labors  of  Farrar,  the  intro- 
duction of  stock  appliances  was  inevitable.  The  wholesale 
construction  of  standard  mechanisms  with  interchangeable 
parts,   to  be  placed  upon  the  market  for  sale,  was  now 

Fig.  98 


Farrar's  "labial  bow"  and  clamp  bands. 


Fig.  99 


Patrick's  appliance. 

demanded.  Naturally,  many  of  the  earlier  efforts  in  this 
direction  were  very  incomplete  and  unsatisfactory,  and  in 
untrained  hands  often  proved  a  failure.  They  were  usually 
brought  forth  in  the  shape  of  a  "system,"  and  represented 
the  more  commonly  used  methods  of  their  author. 


RISE  OF  THE  SYSTEMS 


149 


In  1876,  in  response  to  these  demands,  Dr.  Farrar  offered 
duplicates  of  many  of  the  appliances  he  had  nsed  in  his 
practice  (Fig.  98).  For  a  time  they  enjoyed  an  extended 
sale,  but  were  soon  displaced  by  devices  of  simpler  design, 
notably  those  by  Patrick  in  the  early  80's  (Fig.  99).  A 
study  of  this  ilhistration  reveals  the  principle  of  the  align- 
ment wire  anchored  to  the  molars  by  means  of  adjustable 
bands  with  buccal  tubes. 


Fig.  100 


Angle  appliance  of  1887. 


In  1887  Angle  introduced  a  system  which  embodied 
sundry  of  these  old  principles,  though  greatly  simplified 
by  a  reduction  of  parts  (Fig.  100). 

Among  the  many  other  methods  brought  forward  during 
this  unusually  productive  period  were  the  systems  of  Jack- 
son, Case,  Lukens  (Fig.  101),  and  Knapp. 


150 


THE  EVOLUTION  OF  METHODS 


Recent  adverse  criticism  has  created  considerable  ill 
feeling  in  opposition  to  these  so-called  systems,  which  could 
easily  have  been  avoided  had  their  originators  adhered  to 
the  principles  of  historical  method.     Their  tacit  claims  of 


Fig.  101 


Lukens'  appliance. 


having  suddenly,  and  by  original  methods,  revolutionized 
the  art  and  brought  it  to  an  approximate  finality,  are 
directly  traceable  to  the  wilful  omission  of  the  work  of 
many  predecessors. 

In  Chapter  I  attention  was  called  to  their  achievements, 
to  their  influences  toward  the  simplification  of  methods; 


LINES  OF  ADVANCE  151 

and  so  the  struggle  which  they  themselves  engendered  may 
be  regarded  as  a  passing  cloud — for  systems  are  wholly 
foreign  to  the  democracy  of  science.  Hence  the  thought 
that  they  must  finally  die,  that  upon  their  shattered  dreams 
of  finality  a  greater  and  grander  art  will  rise,  is  encouraging, 
and  not  at  all  dispiriting.  Indeed,  this  forward  movement 
has  now^  begun. 

LINES  OF  ADVANCE 

The  comprehension  of  the  importance  of  a  differential 
diagnosis,  the  designing  of  a  definite  treatment  for  all  cases 
belonging  to  a  given  class,  and  the  simplification  and  mastery 
of  the  technical  details  of  every  such  definite  treatment,  may 
be  said  to  constitute  the  core  of  what  has  been  termed  the 
new  movement  in  orthodontic  practice. 

The  systems  (particularly  the  efforts  of  Angle)  have  been 
largely  responsible  for  promoting  this  advance  in  our 
progress.  And  though  they  were  unbecomingly  dogmatic, 
they  possessed  the  saving  grace  of  showing  the  wide  range 
of  applicability  of  a  limited  number  of  very  simple  mechan- 
isms. Hence  the  burden  of  their  claims  w^as,  after  all,  a 
very  laudable  one;  by  insisting  on  the  mastery  of  a  few  essen- 
tials and  their  manifold  combinations,  orthodontics  made  a 
progress  hitherto  unattainable.  In  fine,  to  be  a  master  in 
the  application  and  use  of  a  few  appliances,  rather  than 
the  slave  of  many,  is  a  worthy  lesson  the  sj^stematists  have 
tried  to  teach.  Ever  since  the  dawn  of  this  tendency  toward 
simplicity  and  the  unification  of  methods,  orthodontics 
has  witnessed  a  wholesome  elimination  of  many  unneces- 
sary^ and  impractical  procedures.  Though  this  process  of 
elimination  still  continues,  at  the  present  writing  it  is  very 


152  THE  EVOLUTION  OF  METHODS 

evident  that  certain  mechanisms  (those  embodying  advanced 
principles  of  design)  are  tending  rapidly  toward  universal 
acceptance. 

DETAILS  OF  DESIGN 

Fig.  102  is  diagrammatic  of  a  modern  appliance,  combin- 
ing many  of  the  essential  elements  in  use  today.  These 
elements  may  briefly  be  summarized  as  follows:  The  plain 
band  {B),  anchor  band  {D),  alignment  wire  {F),  ligatures 
(C  and  A),  and  a  number  of  minor  miscellaneous  accessories 

Fig.  102 


Modern  appliance.     (After  Angle.) 

not  shown  in  the  illustration.  By  the  skilful  and  judicious 
combination  of  these  elements  we  are  enabled  to  treat  most 
cases  of  malocclusion.  Only  rarely  are  we  obliged  to  employ 
other  and  more  complicated  appliances. 

From  the  earliest  times,  several  of  the  noble  metals,  viz., 
gold,  platinum,  silver,  and  their  alloj^s,  have  been  used  in 
the  construction  of  regulating  appliances.  In  recent  years 
base  metal  alloys  like  German  silver  have  been  widely 
employed.       Iron,     steel,     nickel,  aluminum    bronze,     and 


DETAILS  OF  DESIGN  153 

vulcanite  ru])ber  have  all  been  recommended.  German 
silver,  ho\ve\-er,  possesses  many  of  the  virtues  which  should 
be  embodied  in  an  appliance,  such  as  temper,  adaptability 
when  annealed,  inexpensiveness,  etc.  On  the  other  hand, 
Pullen^  and  Grieves^  have  recently  called  attention  to  its 
shortcomings,  which  are  as  follows:  Discoloration  and 
disintegration,  and,  occasionally,  the  formation  of  metallic 
stains  upon  the  tooth  surfaces. 

Alloys  of  iridium  and  platinum,  and  of  gold  and  platinum, 
are  therefore  preferred  b}'  many  operators,  because  they 
are  not  affected  by  the  acid  fluids  of  the  oral  cavity,  or  by 
any  of  the  medicaments  employed  in  practice  (such  as 
hydrogen  peroxide,  solutions  of  silver  nitrate,  tincture  of 
iodine,  etc.). 

When  attention  was  first  called  to  the  corrosion  of  German 
silver,  its  advocates  proclaimed  this  a  virtue,  believing  the 
consequent  liberation  of  metallic  salts  had  a  favorable 
prophjdactic  influence,  promoting  an  immunity  to  caries  of 
the  enamel.  Grieves,^  on  the  other  hand,  has  shown  that 
the  amount  of  metallic  salts  thus  set  free  and  swallowed 
by  the  patient  frequently  proves  deleterious  by  unfavorably 
affecting,  the  physiological  action  of  the  ptyalin  and  enzymes. 
He  claims  zinc  is  the  most  objectionable  of  all  the  metals 
which  enter  into  alloys  used  for  appliances. 

The  introduction  of  aluminum  bronze  into  dentistry  by 
Sauer,  and  its  recent  revival  for  regulating  appliances  by 
Treymann,*  resulting  in  the  so-called  "non-corrosive" 
appliances,  will  doubtless  lead  to  the  discovery  of  base- 
metal  alloys  with  virtues  equal  to  those  of  the  noble  metal 
group.  The  latter,  however,  possess  all  of  the  requisite 
qualifications  except  that  of  cost. 

'  Proc.  Amer.  Soc.  Orthodontists,  vol.  vii.       ^  ibid.,  vols,  viii  and  ix. 

3  Log.  cit.  *  Vierteljahr.  f.  Zahnhk.,  July,  1909. 


CHAPTER    IX 

PRINCIPAL  ELEMENTS  OF  MODERN  MECHANISMS 

BANDS 

The  Plain  Band. — The  individual  movement  of  malposed 
teeth  and  the  correction  of  arch  form  constituted  the  sum 
total  of  orthodontic  efforts  for  many  decades.  Only  recently 
have  the  possibilities  of  arch  movement  been  developed. 
Even  in  those  earlier  stages  of  progress  was  the  need  plainly 
felt  for  some  form  of  attachment  to  the  teeth  to  be  moved. 
Owing  to  the  unfavorable  forms  of  many  of  the  teeth,  the  use 

Fig.  103 


The  plain  band. 

of  simple  ligatures  often  proved  inadequate  for  the  move- 
ments required.  To  gain  secure  attachment  at  the  point 
of  attack,  regardless  of  the  kind  of  mechanism  employed, 
is  the  first  requisite  of  successful  therapy.  Hence  the  plain, 
band  was  invented  (Fig.  103).  It  consists  of  a  ribbon  of 
metal  36  to  38  gauge,  accurately  adapted  to  the  crown  of 
the  tooth  for  which  it  is  designed,  after  which  its  free  ends 


BANDS 


155 


are  united  by  solder   (S)   to  form  a  contiiiiioiis  band,  or 
ferrule. 

As  early  as  1815  Delabarre^  suggested  the  use  of  metallic 
caps,  or  crowns,  for  the  teeth  to  be  moved,  and  to  which 
the  various  attachments  were  soldered.  In  1848  Jos. 
Linderer^  advocated  ribbons  of  metal  for  the  same  purpose. 
These  had  perforations  in  their  ends,  through  which  ligatures 
were  passed,  making  them  adjustable  as  to  size  (Fig.  104). 

Fig.  104 


Linderer's  adjustable  band  on  the  canine.     (After  Pfaff.) 

Magill  and  Gilmer  have  been  credited  with  the  honor  of 
introducing  the  plain  band  as  used  today,  and  of  advocating 
its  secure  attachment  by  means  of  cement.     While  many 


1  Odontologische  Beobachtungen,  Paris,  1815. 
«  Handbucli  der  Zahnheilk.,  Berlin,  1848. 


156     PRINCIPAL  ELEMENTS  OF  MODERN  MECHANISMS 

minor  tooth  movements  are  ])ossible  witliout  its  use,  it  is 
evident  that  the  plain  band  with  its  various  attachments 
will  always  occupy  a  prominent  place  in  the  technique.  A 
detailed  consideration  of  these  various  attachments  and 
their  uses  will  be  found  in  the  chapters  on  treatment. 

The  Anchor  Band. — This  essential  element  of  an  appliance 
has  passed  through  many  stages,  all  of  which  can  readily 
be  grouped  under  the  two  divisions  of  adjustahle  and  non- 
adjustable.  The  non-adjustable  designs  were  the  first  to  be 
used,  and  were  variously  described  as  crowns,  cribs,  clasps, 
and  ferrules.  They  w-ere  constructed  bj'  the  operator,  and 
prior  to  the  introduction  of  cement  were  very  insecure  in 
their  anchorage,  besides  promoting  caries  of  the  enamel. 

The  ferrule  design,  which,  in  reality,  w^as  a  plain  band, 
proved  the  most  efficacious  of  these,  and  still  continues  in 
use.  With  the  introduction  of  the  adjustable  form  of  anchor 
band,  it  was  claimed  that  an  accurate  adjustment  was  more 
readily  obtained.  Owing  to  the  fact  that  anchorage  is 
usually  applied  to  the  molars,  the  crowns  of  which  are  less 
accessible  than  those  of  the  anterior  teeth,  the  adjustable 
designs  readily  met  with  great  favor.  Furthermore,  the  wide 
use  of  stock  appliances  aided  materially  in  their  adoption. 

As  stated,  Linderer  was  probably  the  first  to  use  an 
adjustable  band.  A  decided  advance  in  design  is  shown  in 
Fig.  105,  which  was  introduced  by  Schange  in  1841.^  He 
adopted  the  principle  of  the  threaded  bar,  or  screw,  for 
adjusting  the  size  of  the  band.  Later,  in  the  hands  of 
Farrar,  it  passed  through  various  stages  (Fig.  106).  The 
screw-block  on  the  buccal  surface  was  modified  by  Patrick 
(Fig.  107)  and  Angle  (Fig.  108)  into  the  tube  in  use  today. 

1  Precis  sur  le  redressement  des  denta,  Paris,  1841. 


BANDS 


157 


Even  this  tube,  which  provides  anchorage  for  the  ahgnment 
wire,  has  been  modified  in  design  by  Knapp,  Kemple,  Otto- 
lengui,  and  others.  An  ingenious  modification  is  shown  in  the 
design  by  Lukens  (Fig.  109),  in  which  the  tube  is  threaded 


Fig.  105 


Schange'a  adjustable  band  on  the  central. 
Fig.  106  Fig.  107  Fig.  108 


Farrar's  adjustable  anchor 
band  for  molars. 


Patrick's  adjustable  Angle's  adjustable  anchor 

anchor  band.  band. 


on  its  outer  surface  and  thus  made  to  serve  as  the  screw- 
post,  which  does  away  with  the  attachment  of  the  latter 
on  the  Hngual  surface. 

Fig.   110  shows  the  so-called  all-closing,  or  continuous 


158     PRINCIPAL  ELEMENTS  OF  MODERN  MECHANISMS 

form  suggested  by  Barnes.  This  feature  is  widely  used 
today,  because  it  constitutes  an  additional  precaution 
against  caries  of  the  enamel.  The  recent  introduction  of 
the  "seamless  band"  has  been  favorably  received,  especially 


Fig.   109 


Fig.  110 


Lukens'  adjustable  anchor  band.         All  closing  or  continuous  band.    (After  Barnes.) 

for  the  treatment  of  young  patients.  The  advantage  of  a 
smooth  lingual  surface,  as  emphasized  by  Lukens,  has 
prompted  manufacturers  to  furnish  seamless  bands  in  such 
a  variety  of  sizes  that  an  accurate  fit  is  readily  obtained  in 
most  instances  (Fig.  111). 

Fig.  Ill 


Seamless  ferrules,  from  which  non-adjustable  anchor  bands  can  be  constructed. 

The  use  of  lingual  extension  wires,  as  advocated  by 
Hawley,^  for  the  buccal  movement  of  teeth  mesial  to  the 
first   molars    (Fig.    112),   mairks   another  step  in  advance. 


'  Proc.  Amer.  Soc.  Orthodontists. 


THE  ALIGNMENT  WIRE 


159 


Pullen  has  recently  suggested  a  modification  of  this  principle 
by  extending  the  screw-post  (Fig.  113). 


Fia.  112 


Lingual  extension  wires.    (After  Hawley.) 
Fig.  113 


Showing  continuation  of  the  clamping  bolt.    (After  Pullen.) 


THE  ALIGNMENT  WIRE 

According  to  Farrar,  this  element  was  used  in  the  earliest 
times,  when  it  was  made  of  wood  or  strips  of  bamboo. 
Fauchard  was  probably  the  first  to  apply  it  in  the  shape  of  a 
metal  strip,  as  shown  in  Fig.  95.  jNIany  of  the  mechanisms 
employed  by  Fox,  Schange,  Carabelli,  Harris,  Patrick, 
Farrar,  and  others  embodied  this  element,  when  it  was 
called  the  Jabial  bow.  In  the  design  by  Flagg  (Fig.  97)  it 
is  seen  in  its  simplest  form.  Farrar  and  Patrick  employed 
it   frequently,    and   developed   many   of   its   attachments. 


160     PRINCIPAL  ELEMENTS  OF  MODERN  MECHANISMS 

Fig.  114  shows  the  attachment  of  spurs  for  preventing  the 
slipping  of  ligatures,  as  advocated  by  Farrar.^  This  detail 
has  recently  been  improved  by  Lourie,  whose  spur-cutting 
pliers  for  this  purpose  are  excellent  (Fig.  115). 

Angle's  conclusive  demonstrations  regarding  its  wide 
range  of  applicability  mark  an  epoch  of  no  small  moment 
in  the  treatment  of  malocclusion.  Through  his  efforts  we 
have  learned  that  this  simple  wire  establishes   a  line  of 

Fig.  114 


Farrar's  spur  attachments  to  the  alignment  wire  to  prevent  ligatures  from 
slipping. 

alignment  for  the  correction  of  arch  form  in  advance  of 
tooth  movement;  that  it  serves  as  a  working  basis  for  most 
of  the  individual  tooth  movements;  that  it  may  be  utilized 
both  for  expansion  and  contraction  of  the  dental  arch;  that 
it  is  the  most  efficient  means,  when  properly  manipulated, 
for  arch  movement;  and  finally,  in  the  first  stages  of  reten- 
tion, it  serves  as  an  excellent  retaining  device. 

The  plain  form,  with  threaded  ends  and  nuts,  answers 
every  purpose  in  most  cases,  and  Nos.  16  and  18  gauge 
represent  the  sizes  in  general  use.  Occasionally,  in  patients 
above  ten  years  of  age,  the  dental  arch  may  be  so  contracted 

'  Irregularities,  1888. 


THE  ALIGNMENT   WIRE 


161 


that  lateral  expansion  in  the  region  of  the  canines  can  be 
more  readily  accomplished  by  the  use  of  a  divided  wire 
(Fig.  116),  a  design  advocated  by  Bethel  and  Pullen. 


Fig.  115 


11 


Lourie  spur-cutting  pliers. 


162     PRINCIPAL  ELEMENTS  OF  MODERN  MECHANISMS 

An  attachment  of  great  value  (Fig,  117)  is  that  known  as 
a  tube  hook.   The  tube  fits  the  wire  accurately,  and  is  attached 

Fig.  116 


Di\dded  alignment  wire.     (After  Bethel  and  Pullen.) 

by  means  of  solder  in  the  region  of  the  canines.  This  hook 
engages  elastic  bands,  the  uses  of  which  are  fully  described  in 
the  chapters  on  Treatment. 

Fig.  117 


Intermaxillary  tube  hook.    (After  Angle.) 


LIGATURES  AND  ELASTICS 

The  use  of  ligatures  for  tooth  movement  have  been  advo- 
cated from  time  immemorial.  In  the  works  of  Fauchard, 
Bourdet,  Jourdain,  Linderer,  etc.,  we  find  illustrations  show- 
ing the  manner  of  their  application.  Silk  and  linen  threads 
were  first  emploj'ed  for  this  purpose,  as  well  as  wires  of 
iron,  gold,  and  silver.^    Angle,  in  connection  with  his  appli- 

•  Pfaff,  Lehrbuch. 


MISCELLANEOUS  ACCESSORIES  lt)3 

ances  of  German  silver,  advocated  the  use  of  soft  brass 
wire,  ranging  in  size  from  25  to  30  gauge.  On  the  other  hand, 
many  operators  now  prefer  the  so-called  silk  grass  line, 
recommended  by  Hawley.^  This  revival  of  the  silk  ligature 
is  prompted  largely  by  the  present  use  of  the  noble  metals, 
the  rapid  oxidation  of  which  the  brass  wires  promote;  and 
by  the  tendency  toward  earlier  treatment,  when  the  force 
required  is  considerably  less. 

The  use  of  elastic  rubber  bands  was  advocated  by  Fox 
in  1814,  who  employed  them  in  his  practice.  Lachaise, 
Tucker,  Kingsley,  and  others  continued  their  use  to  the 
present.  While  they  are  still  largely  employed  for  the 
various  movements  of  individual  teeth,  their  greatest  value 
is  in  connection  with  arch  movement.  Case,  Lourie,  Baker, 
and  Angle  have  recently  developed  this  important  detail 
of  treatment,  the  importance  of  which  can  hardly  be  over- 
estimated.   (See  Chapters  XVI  and  XVII.) 

MISCELLANEOUS  ACCESSORIES 

Among  the  countless  mechanisms  that  have  been  designed 
for  the  treatment  of  malocclusion,  there  have  been  very  few, 
indeed,  which  have  achieved  survival.  As  intimated  in 
Chapter  VIII,  only  rarely  are  we  obliged  to  use  appliances 
other  than  those  which  can  be  constructed  out  of  the  elements 
enumerated  above.  And  in  these  rare  instances  a  very  few 
additional  elements  will  suffice,  such  as  the  lever,  the  skull 
cap  for  extramaxillary  or  occipital  anchorage,  the  "Case 
contom-ing  apparatus"  for  the  bodily  movement  of  teeth, 
etc.  The  use  of  these  can  best  be  described  in  the  chapters 
on  Treatment. 

'  Proc.  Ainer.  Soc.  Orthodontists, 


CHAPTER    X 

PRINCIPLES  OF  APPLICATION 

In  the  application  of  every  appliance  we  are  forced  to 
comply  with  certain  fundamental  mechanical  requirements. 
The  main  points  to  be  considered  in  this  connection  are: 
(a)  The  teeth  to  be  moved  (or  the  points  of  attack),  (6)  the 
forces  employed  (or  the  means  by  which  movement  is 
affected),  and  (c)  the  utilizable  resistances  (or  anchorage 
of  the  means).  Pullen'^  has  defined  anchorage  as  "the 
resistance  selected  as  a  base  from  which  force  is  to  be 
delivered  for  the  movement  of  teeth."  Korbitz^  has  very 
aptly  stated  that  "The  art  and  difficulty  of  orthodontic 
technique  does  not  consist  in  the  production  of  the  acting 
forces,  but  of  the  advantageous  utilization  of  the  resistances 
present."  Continuing  he  says:  "In  the  masticating  appa- 
ratus there  is  no  fixed  point  from  which  we  are  able  to  act 
upon  the  individual  teeth.  The  production  of  a  move- 
ment always  requires  a  point  of  anchorage;  the  forces 
employed  act  with  the  same  power  upon  this  point  of 
anchorage  as  upon  the  point  to  be  moved." 

FORMS  OF  ANCHORAGE 

The  resistances  utilized  in  the  movement  of  teeth  may 
be  classified  as  follows: 

•  Operative  Dentistry,  Johnson.  ^  Kvjrsus  der  Orthodontic. 


FORMS  OF  ANCHORAGE 


165 


(a)  As  to  method,  into  stationary  and  reciprocal. 

(6)  As  to  source,  into  intraviaxiUary,  inter maxiUary,  and 
extramaxillary . 

Stationary  Anchorage. — This  term  is  a  merely  relative 
one,  since  there  is  no  absolutely  fixed  point  in  the  dental 

Fig.  118 


Exemplifies  stationary  and  reciprocal  anchorage. 


arches.  It  may  be  described  as  a  rigid  resistance  at  "the 
point  of  departure,"  which  may  be  due  to  the  greater  size 
and  more  abundant  osseous  support  of  the  tooth  utilized, 
to  the  manner  of  attachment  of  the  appliance,  or  to  the 
direction  of  the  force  employed. 

The  appliance  shown  in  Fig.  118  is  intended  to  effect  a 


166  PRINCIPLES  OF  APPLICATION 

mesial  movement  of  the  first  bicuspid.  This  is  accomphshed 
by  the  use  of  a  hgature  attached  to  the  ahgnment  wire. 
The  latter  is  anchored  to  the  molar  by  means  of  an  anchor 
band.  If  the  nut  on  the  wire  is  brought  to  bear  upon  the 
mesial  end  of  the  tube,  the  molar  exemplifies  stationary 
anchorage.  Besides  being  larger,  and  offering  greater  resist- 
ance than  the  first  bicuspid,  it  has  the  additional  support 
of  the  second  molar.  The  cuspid  has  not  yet  erupted, 
and  hence  the  resistance  mesial  to  the  first  bicuspid  will 
yield.  On  the  other  hand,  if  the  crown  of  the  first  bicuspid 
were  inclined  distally,  and  the  first  molar  were  unsup- 
ported by  the  second,  the  tendency  for  a  distal  movement 
of  the  first  molar  might  readily  assert  itself. 

Reciprocal  Anchorage. — A  further  study  of  the  case  reveals 
a  labioversion  of  the  central  incisors.  The  aim  will  be  to 
move  these  lingually,  which  can  easily  be  accomplished  if 
the  nut  is  released  at  the  mesial  end  of  the  tube.  By  so 
doing,  the  alignment  wire  will  glide  distally  within  the  tube 
until  it  bears  upon  the  labial  surfaces  of  the  incisors  at  the 
points  a  a.  The  load  imposed  by  the  tension  of  the  ligature 
from  the  bicuspid  is  now  shared  by  the  incisors,  whose 
combined  resistance  is  less  than  that  of  the  molars.  Hence 
we  no  longer  have  stationary  anchorage;  the  incisors, 
like  the  bicuspid,  will  yield  under  this  stress.  We  term 
this  reciprocal  anchorage,  by  which  means  the  force  is 
utihzed  at  both  "the  point  of  attack"  and  "the  point  of 
departure." 

"In  reciprocal  anchorage  the  reciprocity  of  the  resistance 
points  is  never  quite  perfect.  This  is  due  to  the  diversity 
of  the  resistances  and  to  the  variety  of  the  deviations." 
(Korbitz.) 

If  we  release  the  nut  prior  to  ligating  the  bicuspid,  and 


FORMS  OF  ANCHORAGE 


167 


then  subsequently  tighten  it,  we  can  utiHze  both  forms 
simultaneously.  Indeed,  this  is  the  aim  in  most  instances. 
The  use  of  stationary  anchorage  per  se  is  very  limited,  and 
rarely  as  satisfactory  as  the  reciprocal  form.  Furthermore, 
if  the  anchor  teeth  are  not  carefully  guarded,  they  rarely 
remain  stationary. 

Intramaxillary  Anchorage.  —  Many  of  the  required  tooth 
movements  can  readily  be  performed  by  the  use  of  anchor 
bands  and  the  alignment  wire  in  combination  with  ligatures. 


Fig.  119 


Reciprocal  anchorage. 

Previous  to  its  insertion  within  the  buccal  tubes,  it  is  bent 
to  that  ideal  form  we  wish  ultimately  to  establish.  The  teeth 
in  each  lateral  half  are  then  forced  into  normal  alignment 
by  ligation,  and  by  the  alternate  and  simultaneous  use  of 
stationary  and  reciprocal  anchorage.  Occasionally  we  seek 
the  necessary  resistance  on  the  opposite  side  of  the  dental 
arch,  as  shown  in  Fig.  119.  The  two  upper  cuspids  being 
similarly  malposed,  we  resort  to  the  most  direct  method  of 
the  jack-screw.  This  is  a  good  example  of  reciprocal  anchor- 
age, resulting  in  the  simultaneous  movement  of  the  cuspids. 


168  PRINCIPLES  OF  APPLICATION 

In  all  cases  where  the  resistances  selected  are  in  the  same 
dental  arch  as  the  teeth  to  be  moved  the  term  intramaxillary 
anchorage  is  applied. 

Intermaxillary  Anchorage. — There  are  many  forms  of  mal- 
occlusion which  cannot  be  so  readily  disposed  of,  and  for 
which  we  are  forced  to  seek  anchorage  in  the  opposing  jaw. 
Whenever  we  employ  an  anchorage  thus  located,  we  term 
it  intermaxillary  anchorage.  This  is  also  used  in  both  the 
stationary  and  reciprocal  forms. 

Fig.  120 


Direct  intermaxillary  anchorage.     (After  Angle.) 

In  the  case  shown  in  Fig.  120  we  observe  a  lingual  per- 
version of  the  right  upper  cuspid.  After  removing  the 
superimposed  gum  tissue  and  providing  an  attachment  to 
the  cuspid,  we  can  force  its  eruption  by  means  of  a  small 
elastic-rubber  ring  anchored  to  the  lower  bicuspid  and 
cuspid.  This  constitutes  the  simplest  and  most  direct  form 
of  intermaxillary  anchorage  after  the  manner  indicated  by 
Anglei  in  1891. 

Fig.  121  shows  a  similar  case  complicated  by  a  mesio- 
version  of  the  right  upper  bicuspids  and  molars,  and  linguo- 
version  of  the  permanent  canine  due  to  prolonged  retention 

1  Dental  Cosmos,  September,  1891. 


FORMS  OF  ANCHORAGE 


169 


of  its  temporary  predecessor.  Hence  the  first  step  in  the 
treatment  is  a  distal  movement  of  loiciispids  and  molars. 
This  cannot  be  accomplished  in  the  ordinary  manner;  the 
resistance  offered  by  the  incisors  to  the  mesial  is  not  equal 
to  the  task.  Nor  would  an  anchorage  point  on  the  opposite 
side  of  the  same  dental  arch  be  of  any  value.  We  therefore 
search  for  the  necessary  resistance  in  the  opposing  arch,  as 
suggested  by  Lourie^  (Fig.  122).    In  this  instance  we  secure 

Fig.  121 


Case  requiring  the  use  of  intermaxillary  anchorage  for  its  correction. 

stationary  anchorage  in  the  lower  by  ligating  several  of  the 
anterior  teeth  to  the  alignment  arch  and  so  adjusting  the 
nut  that  it  comes  into  contact  with  the  mesial  ends  of  the 
buccal  tube.  In  the  upper  arch  the  nut  is  adjusted  so  that 
the  alignment  wire  does  not  touch  the  labial  and  buccal 
surfaces  of  the  teeth  mesial  to  the  molars.     Hence  the 


1  Amer.  See.  Orthodontists,  1902. 


170  PRINCIPLES  OF  APPLICATION 

combined  resistances  of  the  lower  teeth,  by  means  of  the 
elastic  bands,  is  thrown  against  the  upper  molar,  forcing  it 
distally.  After  sufficient  distal  movement  of  the  molars  has 
been  gained,  the  attachment  is  changed  to  the  bicuspids  and 
these  in  turn  moved  distally. 

Fig    122 


^^/!!j;niiJ!Ji))j)i))i!im)jnTTT. 


^/;w/mwwwwnwwwj777r. 

Mechanism  employed  for  intermaxillary  anchorage. 

Recent  advances  in  the  use  of  intermaxillary  anchorage 
have  so  enlarged  its  field  of  application  that  it  has  become 
the  most  valuable  of  all.  The  wide  range  of  its  applicability 
constitutes  one  of  the  most  important  steps  in  orthodontic 
progress;  without  it,  the  correction  of  arch  malrelation  would 
be  extremely  difficult,  if  not  impossible.  (See  Chapters  XVI 
and  XVII.) 

Extramaxillary  Anchorage. — Prior  to  the  perfection  of 
intermaxillary  anchorage,  many  of  the  pronounced  forms  of 
malocclusion  (such  as  mesioclusion  and  distoclusion)  were 
treated  by  means  of  occipital  anchorage.  This  was  obtained 
by  the  wearing  of  a  cap,  or  network  with  frame,  adjusted 
to  the  back  of  the  head,  to  which  the  chin  cap  or  cross-bar 
was  attached  by  means  of  heavy  elastics  (Figs.  123  and 
124).  This  form  constitutes  the  best  type  of  stationary 
anchorage,  but  unfortunately  is  under  the  patient's  control. 
It  is  extremely   annoying   and   conspicuous,  and  is   now 


FORMS  OF  ANCHORAGE 

Fig.  123 


Extramaxillarj  anchorage      ( '^fter  Angle.) 
'  Fig.  124 


Extramaxillary  anchorage.    (After  Angle.) 


172  PRINCIPLES  OF  APPLICATION 

rarely  employed,  owing  to  the  recent  advances  in  the  use  of 
intermaxillary  anchorage. 

To  the  beginner,  a  discussion  of  the  problems  of  anchor- 
age may  seem  as  a  mass  of  trivial  reflections ;  in  reality,  they 
constitute  some  of  the  hardest  lessons  to  be  learned.  A 
mastery  of  these  principles  enables  one  to  accomplish  truly 
remarkable  results  with  the  very  simplest  mechanisms. 
Ignorance,  on  the  other  hand,  yields  consequences  quite 
unexpected.  An  exhaustive  study  of  the  principles  of 
anchorage,  theoretical  as  well  as  practical,  is  therefore 
advisable.  "They  must  be  transfused  into  our  flesh  and 
blood,  so  that  we  may  employ  them  automatically  in  our 
practice;  just  as  we  use  the  multiplication  table  in  calcu- 
lation."    (Korbitz.) 


CHAPTER    XI 

DETAILS  OF  APPLICATION 

In  preceding  chapters  many  of  the  preHminaries  for 
treatment  were  described.  The  next  step  is  a  detailed 
consideration  of  the  plan  of  treatment,  which  should  always 
be  carefully  worked  out  beforehand  and  in  accordance  with 
a  definite  routine.  An  operator  must  always  be  mindful 
of  the  many  necessary  details,  and  then  firmly  resolve  to 
carry  them  out. 

BANDS 

The  Anchor  Band. — As  intimated  in  Chapter  X,  a  compli- 
ance with  fundamental  mechanical  principles  is  imperative; 
hence  the  anchorage  of  the  appliance  should  receive  first 
consideration.  In  view  of  the  fact  that  this  is  provided 
in  most  instances  by  the  use  of  anchor  bands,  the  details 
of  their  application  are  important.  A  very  limited  experi- 
ence readily  emphasizes  the  fact  that  the  first  permanent 
molars  are  preferable  to  any  other  teeth  in  the  arch  for 
purposes  of  anchorage,  owing  to  their  large  size  and  early 
calcification.  Only  in  rare  instances,  owing  to  the  absence 
of  these  teeth,  are  we  compelled  to  utilize  the  second  molars 
or  bicuspids. 

After  a  decision  has  been  reached  as  to  the  teeth  to  be 
utilized,  the  selection  of  an  anchor  band  should  be  made. 
The  author  prefers  an  all-closing  adjustable  band,  as  shown 
in  Fig.  110.    Prior  to  its  insertion  it  is  contoured  to  approxi- 


174  DETAILS  OF  APPLICATION 

mate  the  form  of  the  tooth  upon  which  it  is  to  be  placed. 
It  is  frequently  necessary  to  bend  the  screw-post  on  the 
lingual  side,  so  that  it  closely  embraces  the  tooth  to  the 
mesial.  In  case  the  second  molars  have  erupted,  and  lateral 
expansion  in  this  region  is  indicated,  it  may  be  advisable 
to  place  the  band  so  that  the  bolt  will  point  in  a  distal 
direction  (compare  Fig.  118).  The  protrusion  of  the  screw- 
post  into  the  oral  space  toward  the  tongue  is  never  necessary 
if  care  is  exercised  in  the  adjustment.  The  mesial  portion 
of  the  band  should  always  be  forced  well  up  under  the  gum, 

Fig.  125 


Shows  correct  adaptation  of  anchor  band  to  a  molar.    (After  Angle.) 

and  the  distal  slightly  burnished  over  the  distal  marginal 
ridge  to  prevent  displacement.^  The  tubes  being  soldered 
parallel  with  the  borders  of  the  band,  this  manner  of  adjust- 
ment will  effect  a  proper  occlusogingival  alignment  of  the 
buccal  tubes  (Fig.  125). 

In  very  young  patients  (owing  to  a  superabundance  of 
gum  tissue),  and  in  cases  of  infra  version  of  the  molars,  it  is 
best  to  use  a  seamless  band.  This  is  first  adjusted  without 
a  tube,  which  latter  is  soldered  on  subsequently. 

All  anchor  bands  should  be  of  the  proper  size  and  accu- 
rately  adjusted,   and   they  should  invariably   be  set  with 

1  Angle,  Malocclusion  of  the  Teeth, 


BANDS  175 

cement.  Cementation  is  always  deferred  until  the  second 
sitting,  Avhen  the  anchor  teeth  are  again  thoroughly  cleansed 
with  pumice  and  washed  with  alcohol,  the  saliva  excluded 
by  means  of  cotton  rolls,  and  dryness  maintained. 

The  Plain  Band. — The  next  step  is  to  determine  which 
teeth  will  require  plain  bands,  and  the  various  attachments 
for  each  band.  The  form  of  a  tooth  and  its  required  move- 
ments will  usually  settle  this.  For  most  patients  the  adap- 
tation of  the  band  metal  is  readily  accomplished;  but  if 
firmly  established  contact  points  interfere  with  the  adapta- 
tion, it  is  best  to  separate  the  teeth  by  means  of  a  separator, 
or  by  the  insertion  of  tape,  for  twenty-four  hours. 

Fig.  126 


Double  end  burnisher  (Woodson  No.  3). 

After  all  the  bands  in  one  arch  are  thus  prepared,  they 
are  laid  to  one  side,  and  the  anchor  bands  of  that  arch  are 
adjusted.  The  patient  is  now  dismissed,  and  during  the 
interim  prior  to  a  subsequent  ^•isit  the  plain  bands  are 
constructed  and  finished.  Upon  the  patient's  return  each 
band  so  constructed  is  placed  upon  the  tooth  for  which  it  was 
prepared.  This  can  usually  be  effected  with  the  fingers  and 
one  or  two  gentle  blows  from  a  mallet  on  a  band  driver.  A 
more  accurate  fit  can  now  be  obtained  by  frequent  burnishing 
with  the  double  end  instrument  shown  in  Fig.  126. 

The  bands  are  now  remo\'ed  without  changing  their  form, 
and  placed  upon  the  operating  table.  Their  inner  surfaces 
are  cleansed  with  alcohol,  and  the  operating  table  prepared 


176  DETAILS  OF  APPLICATION 

for  cementing  them  into  place.  The  teeth  to  be  banded  are 
again  thoroughly  cleaned  with  powdered  pumice,  and  a 
polishing  point  in  the  dental  engine,  after  which  they  are 
isolated  with  a  napkin  or  cotton  roll.  After  washing  the 
tooth  with  alcohol  and  drying  with  compressed  air,  the 
inner  surface  of  the  band  is  lined  with  a  coat  of  cement  and 
placed  in  position.  The  final  adjustment  is  best  accomplished 
with  a  band  driver  and  mallet  and  the  burnisher.  The 
surplus  cement  is  now  removed  and  the  exclusion  of  moisture 
continued  until  the  remaining  cement  has  thoroughly 
hardened. 

In  cases  where  there  is  considerable  crowding,  and  where 
two  or  more  adjoining  teeth  all  require  bands,  the  double 
thickness  of  metal  in  each  interproximal  space  will  occa- 
sionally interfere  with  their  ready  insertion.  A  good  plan 
in  such  instances  is  to  adjust  the  bands  without  cement, 
and  to  dismiss  the  patient  for  twenty-four  hours,  after  which 
sufficient  separation  will  have  been  gained. 

All  bands  should  fit  accurately,  and  all  attachments 
should  be  well  soldered  and  highly  polished. 

THE  ALIGNMENT  WIRE 

Following  the  adjustment  of  the  plain  and  anchor  bands, 
an  alignment  wire  is  adapted  to  complete  the  appliance. 
The  sizes  in  common  use  are  of  16  and  18  gauge,  and  they 
are  furnished  sufficiently  long  for  all  cases.  They  are 
shaped  to  an  ideal  form  by  the  manufacturer,  and  must, 
therefore,  be  bent  to  conform  to  the  requirements  of  a 
given  case  and  cut  to  exact  length.  This  preliminary  adap- 
tation can  partly  be  executed  on  the  model,  and  partly  by 
trial  insertions  in  the  mouth. 


THE  ALIGNMENT  WIRE 


111 


During  the  adjustment  of  the  anchor  bands  the  subse- 
quent insertion  of  the  wire  within  the  tubes  must  be  kept 


Fia.  127 


Properly  shaped  alignment  wire. 
FiQ.  128 


Improperly  shaped  alignment  wire. 


ill  mind.     In  other  words,  the  two  buccal  tubes  on  opposite 
sides  of  the  dental  arch  should  occupy  a  common  plane, 


12 


178  DETAILS  OF  APPLICATION 

with  the  mesial  ends  of  the  tubes  pointing  shghtly  toward 
the  gingival.  Viewed  in  their  buccal,  or  horizontal,  aspects, 
the  threaded  ends  of  the  wire  appear  as  in  Fig.  127.  The 
careless  adjustment  of  the  buccal  tubes  and  of  the  align- 
ment wire  will  result  in  the  improperly  shaped  appliance 
shown  in  Fig.  128.^ 

Occasionally,  it  is  permissible  to  bend  the  wire  mesial  to 
the  nuts  (Fig.  129),  or  in  the  region  of  the  cuspids  (Fig. 
130),  to  effect  the  proper  alignment  in  the  incisal  area.    In 

Fig.  129 


Bending  the  wire  immediately  mesial  to  the  buccal  tubes  to  gain  correct 
alignment. 


Fig.  130 


Bending  the  wire  in  the  region  of  the  cuspids. 

cases  where  intermaxillary  anchorage  is  employed,  it  is 
best  to  avoid  this,  and  to  procure  correct  alignment  by 
resoldering  the  anchor  tubes. 

Viewed  from  an  occlusal  aspect,  the  free  ends  of  the 
alignment  wire  must  again  receive  careful  attention.  A 
proper  relation  to  the  dental  arch  can  readily  be  secured  by 
bending  with  a  pair  of  clasp  pliers,  and  by  repeated  trials 
of  one  end  within  a  tube,  as  shown  in  Figs.  131  and  132. 
By  means  of  the  pliers  we  can  produce  an  expansion  or  con- 

1  Korbitz,  Kursus  der  Orthodontie. 


THE  ALIGNMENT  WIRE 


179 


traction  of  the  wire,  in  whole  or  in  part,  depending  on  their 
position  and  manner  of  appHcation.^    (Figs.  133  and  134.) 


Fig.  131 


Fig.  132 


Shows  the  adaptation  of  the  ends  of  the  wire. 

After  a  correct  adaptation  has  been  effected,  the  wire  is 
inserted  in  both  tubes  and  allowed  to  remain  in  a  merely 
passive  state,  our  first  aim  being  to  accustom  the  patient 
to  its  presence  within  the  mouth.  In  cases  where  it  mast 
encircle  an  extreme  labioversion  of  one  or  more  teeth  it  may 
be  necessary  to  give  it  a  decidedly  abnormal  form,  to  avoid 

1  Korbitz,  Kursus  dor  Orthodontic. 


180  DETAILS  OF  APPLICATION 

Fig.  133 


Producing  an  expanding  action  over  its  entire  length. 


Fig.  134 


Restricting  the  expanding  action;  by  reversing  the  beaks  of  the  pliers  a  contracting 
action  can  be  obtained. 


LIGATURES  AND  ELASTICS  181 

undue  prominence.  Only  subsequently,  after  considerable 
movement  of  the  adjoining  teeth,  do  we  give  it  that  ideal 
form  we  wish  to  establish. 


LIGATURES  AND  ELASTICS 

Many  movements  of  the  teeth  are  accomplished  by  the 
use  of  ligatures.  As  previously  stated,  the  silk  grass  line 
(which  comes  in  three  sizes,  heavy,  medium,  and  light) 
is  widely  used  for  this  purpose.  Occasionally,  owing  to  the 
position  and  form  of  a  tooth  (particularly  lower  cuspids), 
a  wire  ligature  is  more  effective.  These  are  usually  from  25 
to  30  gauge  thick,  and  made  of  soft,  annealed  brass. 

All  ligatures  should  be  of  generous  length,  to  permit 
of  a  firm  grasp  while  applying  them.  Wire  ligatures  are 
tightened  by  twisting,  and  silk  ligatures  by  tying  in  a  surgical 
knot.  The  more  important  ways  of  using  a  ligature  are 
shown  in  Fig.  102.  Owing  to  the  absorption  of  moisture, 
the  silk  ligature  continues  in  its  tension  for  a  considerable 
period,  often  a  week  or  more.  The  spring  of  the  alignment 
wire  also  aids  in  prolonging  their  action.  Wire  ligatures 
can  be  tightened  by  additional  twisting,  thus  obviating 
their  frequent  renewal. 

Elastic  rubber  bands  are  widely  used  in  present-day 
practice,  particularly  in  intermaxillary  anchorage.  Occa- 
sionally, they  are  of  value  in  intramaxillary  anchorage,  e.  g., 
in  rotation  of  a  bicuspid  (Fig.  163).  A  liberal  supply  should 
always  be  kept  in  stock,  varying  in  size  from  an  "election 
ring"  to  those  made  from  |-inch  pure  rubber  tubing.  The 
former  are  used  principally  in  the  treatment  of  mesioclusion 
and  distoclusion,  for  reenforcement  of  anchorage,  and  for 
reduction  of  extreme  labioversion  of  the  upper  incisors.    The 


182  DETAILS  OF  APPLICATION 

small  sizes  are  employed  for  direct  intermaxillary  anchorage 
for  the  correction  of  infraversion  (Fig.  120).  In  the  latter 
method  they  are  usually  limited  to  the  hours  of  sleep,  while 
in  the  former  they  can  be  worn  constantly.  The  patient 
should  be  taught  the  manner  of  their  application,  and 
provided  with  a  sufficient  number  for  frequent  renewal. 
Owing  to  the  fact  that  their  action  is  constant,  they  require 
careful  supervision  to  prevent  undue  displacement  of  the 
anchor  teeth,  as  well  as  the  teeth  to  be  moved. 


CHAPTER    XII 

PRINCIPLES  OF  RETENTION 

TISSUE  CHANGES  CAUSED  BY  TOOTH  MOVEMENT 

During  tooth  movement  a  number  of  very  important 
changes  are  produced  in  the  tissues  of  attachment.  All 
authorities  are  agreed  that  the  immediate  result  of  the 
application  of  force  is  a  compression  of  the  fibers  of  the 
pericementum  on  the  side  toward  which  a  tooth  is  moved, 
and  a  stretching  of  those  on  the  opposite  side.  In  the  first 
stages  following  pressure  a  feeling  of  pain  is  frequently 
induced,  due  to  mechanical  irritation  of  the  nerves  in  this 
membrane.  This  speedily  ceases  if  the  pressure  is  constant, 
and  is  followed  by  hyperemia.  Latei,  an  absorption  of 
the  resisting  alveolar  plates  is  produced  by  osteoclasts, 
or  "bone-destroying"  cells,  which  make  their  appearance. 
The  mechanism  of  this  process  of  destruction  is  not  yet 
fully  understood,  though  many  theories  have  been  advanced 
as  to  the  probable  cause  of  the  molecular  dissolution  of 
the  osseous  support. 

Some  observers  have  maintained  that  in  many  instances 
a  bending  of  the  alveolar  plates  (and  even  fracture)  takes 
place;  and  occasionally  an  opening  of  the  maxillary  suture 
has  been  induced  by  rapid  lateral  expansion  of  the  upper 
arch  for  young  patients.^ 

The  manifold  functions  of  the  pericementum  exercise  an 
exceedingly  favorable  influence  during  these  serious  stages 

'See  Proc.  Amer.  Soc.  Orthodontists,  1911. 


184  PRINCIPLES  OF  RETENTION 

of  destruction  and  the  repair  which  follows.  The  deposition 
of  bone  on  the  side  from  which  a  tooth  is  moved  is  controlled 
by  osteoblasts,  or  "bone-building"  cells,  but  is  far  less  rapid 
than  absorption  and  tooth  movement. 

DEFINITION 

Owing  to  the  fact,  then,  that  the  osseous  support  of  the 
teeth  is  more  or  less  destroyed  by  the  process  of  absorption, 
and  the  subsequent  formation  of  new  bone  considerably 
prolonged,  it  leaves  them  suspended  by  their  soft,  peri- 
cemental attachments  in  greatly  enlarged  sockets.  The 
length  of  this  period'  of  inadequate  maintenance  varies  in 
different  individuals,  during  which  time  the  fibers  of  the 
pericementum  tend  to  force  the  teeth  back  to  their  former 
abnormal  positions.  This  necessitates  the  application  of 
mechanisms  for  the  purpose  of  retaining  the  teeth  in  their 
new  positions  until  this  tendency  has  subsided  and  socket 
repair  has  been  completed.  Retention  may,  therefore,  be 
defined  "as  the  maintenance  of  sufficient  antagonism  to  the 
forces  tending  to  cause  the  return  of  a  corrected  malocclusion 
to  its  original  condition,  to  insure  permanency  of  the  normal 
relationships  of  occlusion  which  have  been  established." 
(Puhen.i) 

Other  factors  besides  that  of  age  which  may  influence  the 
time  required  and  the  ultimate  success  of  retention,  are  the 
general  and  oral  health  of  the  individual,  the  kind  and  extent 
of  movement  accomplished,  the  detection  and  removal  of 
causative  factors,  and  the  occlusal  contact  established. 
Pathological    conditions     of    the    pericementum    militate 

1  Items  of  Interest,  April,  1907. 


DEFINITION  185 

against  successful  retention.  Nasal  obstruction,  i)ernicious 
habits,  and  other  causative  factors,  when  present,  must 
always  be  removed  or  corrected.  And  Walkhoff^  long  ago 
pointed  out  that  "the  placing  of  the  teeth  into  normal 
articulation  (occlusion)  is  a  fundamental  postulate  in  the 
treatment  of  malocclusion,  insuring  permanent  results." 
Or,  as  Angle^  puts  it,  "It  cannot  be  too  strongly  insisted 
upon  that  the  permanency  of  the  teeth  in  their  new  positions 
cannot  be  hoped  for,  regardless  of  the  length  of  time  the 
retaining  devices  have  been  worn,  unless  such  occlusion 
has  been  established  as  will  enable  the  inclined  planes  of 
the  cusps  to  ultimately  act  in  perfect  harmony  for  mutual 
support." 

In  designing  a  retaining  appliance  it  is  imperative  that 
we  study  the  probable  movement  of  each  individual  tooth 
in  its  tendency  toward  its  original  position.  This  can 
only  be  done  by  comparing  the  original  models  with  the 
ideal  that  has  been  established.  In  the  words  of  Angle,  the 
underlying  principle  of  design  should  be  "to  antagonize  the 
movement  of  the  teeth  only  in  the  direction  of  their  tendencies. 
Very  slight  antagonism  is  required,  hut  its  exercise  must  he 
constant." 

The  time  required  for  successful  retention  varies  from 
three  weeks  to  three  years,  and  in  rare  instances  it  is  neces- 
sary to  resort  to  permanent  retention.  All  uncemented 
contact  points  of  a  retention  appliance  should  be  reduced 
to  the  minimum,  to  prevent  caries  of  the  enamel,  and  all 
bands  securely  cemented  to  the  teeth  to  which  they  are 
attached. 

1  Die  Unregelmassigkeiten  in  den  Zahnstellungen,  Leipzig,  1S91,  p.  37. 

2  Malocclusion  of  the  Teeth,  1907,  p.  263. 


186  PRINCIPLES  OF  RETENTION 


MAINTENANCE  OF  TOOTH  POSITION 

Innumerable  mechanisms  for  retention  have  been  sug- 
gested, dating  back  to  the  ferrule,  or  plain  band,  used  by 
Disarabode  in  1823.  The  appliances  in  use  today  are  the 
result  of  countless  efforts,  and  they  have  passed  through 
many  modifications.  There  can  no  longer  be  any  doubt, 
however,  that  plain  bands  and  their  many  combinations, 
as  suggested  by  Farrar,  Guilford,  Case,  Angle,  and  others, 
constitute  the  best  and  most  widely  used  designs. 


Plain  band  with  two  spurs  for  maintaining  a  corrected  torsoversion.    (After  Angle.) 

Fig.  135  shows  a  band  (F)  upon  an  upper  lateral  which 
has  been  rotated.  After  accurate  adaptation  the  band  is 
removed  and  one  or  two  spurs  {G)  are  attached  with  solder, 
as  may  be  indicated.  The  spurs  should  be  of  sufficient 
length  to  engage  the  adjoining  teeth  (though  not  too  long) 
after  which  the  appliance  is  polished  and  set  with  cement. 
In  most  cases  of  malocclusion  the  treatment  involves  the 
movement  of  several  adjoining  teeth,  hence  the  retainer 
should  be  planned  so  as  to  include  as  many  as  possible, 
thereby  gaining  simpHcity  of  design.  Figs.  136,  137,  and 
138  illustrate  designs  by  Angle  in  which  this  principle  has 
been  carried  out.     They  consist  of  plain  bands  united  by 


MAINTENANCE  OF  ARCH  FORM 


187 


connecting  wires,  the  dotted  lines  indicating  the  preexisting 
malocckisions. 


Fig.  13G 


Fig.  137 


Fig.  138 


Showing  advantageous  combinations  of  the  plain  band  with  connecting  wires. 
(After  Angle.) 


MAINTENANCE  OF  ARCH  FORM 

The  treatment  of  malocchision  invariably  implies  the  cor- 
rection of  arch  form,  and  in  all  cases  where  this  is  extensive 
the  posterior  teeth  are  necessarily  involved.  Not  infrequently 
this  includes  the  buccal  movement  of  bicuspids  and  molars, 
whose  subsequent  lingual  tendencies  must  therefore  be 
counteracted.  In  1873  Farrar^  introduced  vulcanite  plates 
for  this  purpose,  which  have  been  in  use  ever  since  (Fig.  139). 
Such  plates  have  passed  through  a  variety  of  designs,  and  many 
convenient  attachments  to  them  have  been  recommended. 
But  as  Guilf ord^  says :  "  Their  use  is  open  to  certain  objections. 
All  plates,  used  either  for  correction  or  retention,  must  be  re- 
moved at  frequent  intervals  for  cleansing.  The  very  necessity 
for  their  removal  affords  opportunity  for  the  patient  to 


Irregularities,  i,  366. 
Orthodontia,  4th  edition,  p.  129. 


188 


PRINCIPLES  OF  RETENTION 


remove  them  at  other  times,  and  possibly  forget  or  wilfully 
neglect  to  reinsert  them  for  a  longer  or  shorter  period,  thus 
causing  delay  in  the  reparative  process." 


Fig.  139 


K  f ;, 


I'' 


'3 


Vulcanite  plate  advocated  for  maintenance  of  arch  form  in  the  posterior  teeth. 

Fig.   140 


Retention  apparatus  embracing  the  entire  arch. 

Owing  to  their  unreliability,  they  have  therefore  been 
largely  discarded  and  replaced  by  non-removable  appliances. 
For  maintaining  the  corrected  arch  form  the  lingual  extension 
wires  advocated  by  Case,  Watson,  and  Lourie  have  found 
general  favor.  Fig.  140  shows  the  author's  modification, 
and  consists  of  two  molar  bands  and  an  18-  or  20-gauge 


MAINTENANCE  OF  ARCH  RELATION  189 

iridioplatinum  wire  constructed  in  three  sections.  Section 
a  accurately  follows  the  arc  described  by  the  six  anterior 
teeth,  and  its  ends  are  extended  into  the  interproximal 
spaces  distal  to  the  cuspids.  Sections  h  and  c  connect  this 
with  the  anchor  bands.  The  bands  on  the  cuspids  are 
provided  with  spurs  to  prevent  displacement  of  the  wire, 
but  are  not  attached  to  it.  These  bands  are  cemented  into 
place  prior  to  inserting  the  remaining  apparatus.  This 
appliance  permits  of  many  modifications,  which  will  be 
referred  to  in  the  chapters  on  Treatment. 

MAINTENANCE  OF  ARCH  RELATION 

The  correction  of  arch  malrelation  (mesio-and  distoclusion), 
without  resorting  to  the  extraction  of  permanent  teeth,  prob- 
ably dates  back  to  Catalan's  planum  indinatum  and  Kingsley's 
hite-plate  for  "jumping  the  bite."     Recent  advances  in  the 

Fig.   141  .  Fig.  142 


Antagonizing  spur  retainers.     (After  Angle.) 

treatment  of  these  deviations  necessitated  improvements  in 
the  methods  of  retention.  The  principle  of  this  inclined  plane 
in  the  form  of  antagonizing  spurs  (Figs.  141  and  142)  has  been 
advocated  by  Angle  for  this  purpose.  This  method  imposes 
a  severe  strain  upon  the  anchor  teeth,  and  frequently  results 
in  their  displacement.  ]\Iany  operators  have  sought  to 
avoid  this,  and  now  place  chief  reliance  in  a  continuation  of 


190 


PRINCIPLES  OF  RETENTION 


the  intermaxillary  anchorage  used  in  correction,  though  in  a 
weakened  and  modified  form.^ 

Fig.  143  shows  an  appliance  designed  for  this  purpose  in  a 
case  of  bilateral  distoclusion.  Each  arch  is  provided  with 
an  appliance  for  the  maintenance  of  the  corrected  arch 
form.  On  the  upper,  canine  bands  with  delicate  hooks  of 
20-gauge  iridioplatinum  wire  are  provided  for  the  attach- 
ment of  light  elastic  rings.  The  latter  are  stretched  to 
hooks  on  the  buccal  surfaces  of  the  lower  molar  bands,  and 

Fia.  143 


Showing  the  continuation  of  the  intermaxillary  elastic  for  the  maintenance  of 
a  corrected  distoclusion.     (After  Pullen.) 

are  worn  at  night.     During  the  last  stages  of  retention  the 
elastics  are  worn  on  alternate  nights. 

In  mesioclusions  the  attachments  are  placed  on  the  lower 
cuspid  and  upper  molar  bands,  and  the  stretching  of  the 
elastics  is  reversed.  In  unilateral  deviations  the  elastic  is 
worn  only  on  the  side  originalh'  abnormal.  For  further 
designs  and  their  modification  the  reader  is  referred  to 
the  chapters  on  Treatment. 

I  See  Watson,  Proc.  Amer.  Soc.  Orthodontists,  1908;  Rogers,  Ibid.,  1909  and  1910. 


PART    II 
THE  METHODS  OF  TREATMENT 

CHAPTER    XIII 

TREATMENT  OF  MALPOSITION  OF  THE  TEETH 

Technically,  every  treatment  of  malocclusion  embraces 
two  or  more  of  the  following  rudimentary  principles:  The 
correction  of  (a)  tooth  position,  (b)  arch  form,  (c)  arch 
relation,  and,  conjointly,  of  jaw  and  face  deformity.  It  has 
already  been  pointed  out  that  a  tooth  may  occupy  any  one 
of  nine  possible  malpositions  and  their  various  combina- 
tions, and  we  now  approach  the  technical  details  of  their 
treatment. 

LABIOVERSION  AND  BUCCOVERSION 

The  term  labioversion  is  used  to  denote  labially  malposed 
incisors  and  cuspids,  and  huccomrsion  for  buccal  malpositions 
of  the  bicuspids  and  molars.  These  two  terms  are  here 
grouped  together  because  their  treatment  is  similar,  imply- 
ing a  lingual  (or  inward)  mo\'ement  in  each  instance.  For- 
merly, the  use  of  special  apparatus  for  the  treatment  of 
these  deviations  was  considered  a  necessity  (Figs.  144  and 
145);  but  it  rarely  happens  that  only  one  tooth  is  in  mal- 


192      TREATMENT  OF  MALPOSITION  OF   THE   TEETH 

occlusion.  A  careful  study  of  occlusal  relation  usually  leads 
to  the  discovery  of  malposition  in  adjoining  and  opposing 
teeth.  Furthermore,  the  wide  range  of  applicability  of  the 
alignment  wire  and  its  accessories  (by  utilizing  the  various 
forms  of  anchorage)  has  rendered  it   possible  to  carry  out 


Fig.  144 


Discarded  methods  for  the  correction  of  labioversion. 

most  lingual  movements  without  resorting  to  the  use  of 
special  mechanisms.  In  fact,  it  is  our  constant  aim  to  avoid 
special  appliances,  and  to  design  new  uses  for  those  already 
employed. 

Happily,  in  most  instances  the  teeth  immediately  mesial 
and   distal   to   a   labioversion   are   in   linguo version.     The 


LABIOVERSION  AND  BUCCOVERSION  193 

undue  prominence  of  a  labioversion  may  thus  be  advan- 
tageous, permitting  the  vise  of  reciprocal  anchorage.  In 
adjusting  the  ahgnment  wire  for  a  case  as  shown  in  Fig.  146, 
it  invariably  fails  to  come  in  contact  with  the  labial  and 
buccal  eminences  of  the  teeth  adjoining  the  cuspid.  The 
labial  mo\ements  of  the  lateral  incisor  and  first  bicuspid  are 
accomplished  by  ligation  to  the  wire,  which  is  so  adjusted 
as  to  come  in  contact  with  the  labial  ridge  of  the  cuspid. 
By  previously  releasing  the  nut  mesial  to  the  buccal  tube,  it 
will  be  permitted  to  rest  passively,  and  glide  "inwardly," 
within  the  tube.  The  force  exerted  upon  the  lateral  and 
bicuspid  will  be  equally  delivered  upon  the  cuspid,  producing 
a  lingual  movement  in  the  latter.  In  attempting  a  move- 
ment of  this  kind,  it  should  always  be  remembered  that  the 
necessary  mesiodistal  spaces  for  each  tooth  must  be  within 
the  range  of  possibility.  Considerable  expansion  of  the 
dental  arch  is,  therefore,  frequently  indicated,  and  clearly 
impossible  if  we  employ  a  mechanism  as  shown  in  Fig.  144. 
The  extraction  of  the  first  bicuspid  for  the  accommodation 
of  the  cuspid,  as  shown  in  Fig.  145,  is  rarely  if  ever  considered 
justifiable. 

Frequently,  in  crowded  arches,  the  complete  labial  move- 
ment of  the  incisor  and  buccal  movement  of  the  bicuspid 
will  not  progress  uniformly  with  the  final  adjustment  of  the 
cuspid,  in  which  e^'ent  we  resort  to  the  use  of  the  rubber 
wedge  (Fig.  147).  The  ligatures  employed  for  the  lateral 
and  bicuspid,  and  the  nut  in  front  of  the  buccal  tube,  will 
provide  stationary  anchorage  for  the  alignment  wire,  and 
thus  aftord  the  necessary  resistance  for  the  rubber.  This  is 
a  very  effective  method  for  accomplishing  lingual  movements 
in  cuspids,  and  through  reciprocal  action,  labial  movements 
of  the  adjoining  teeth.  A  further  utilization  of  this  principle 
13 


194     TREATMENT  OF  MALPOSITION  OF  THE  TEETH 

is  shown  in  Fig.  148,  for  the  correction  of  buccoversion  of 
a  second  bicuspid  and  hnguo version  of  a  first  bicuspid. 
The  use  of  intermaxillary  anchorage  for  the  reduction  of 
labioversion  of  the  incisors  in  neutroclusion  and  distoclusion 
is  described  in  subsequent  chapters. 


Fig.  146 


Fig.  147 


Illustrates  the  use  of  reciprocal 
anchorage. 


Intensifying  the  pressure  by  means  of  the 
rubber  wedge. 
Fig.  148 


Advantageous  utilization  of  reciprocal  anchorage. 

Buccoversion  of  the  molars  is  comparatively  rare,  and  can, 
in  most  instances,  be  corrected  by  utilizing  the  spring 
temper  of  the  alignment  wire.  By  reversing  the  beaks  of  the 
pliers  shown  in  Figs.  133  and  134,  a  contraction  of  the  arch 
can  be  effected. 


LINGUOVERSION  195 


LINGUOVERSION 

This  is  a  very  common  form  of  malposition,  and  the 
methods  for  its  correction  are  numerous.  One  of  the  most 
powerful  and  satisfactory  methods  at  our  command  is- 
illustrated  in  Fig.  119.  However,  such  instances  are  ex- 
tremely rare;  linguoversion  is  usually  associated  with  labio- 
version  of  the  adjoining  teeth.  Hence  the  alignment  wire, 
by  means  of  which  we  can  accomplish  all  of  the  various 
movements,  is  to  be  preferred. 

As  previously  intimated,  outward  movements  can  readily 
be  accomplished  simultaneously  with  lingual  or  inward  move- 
ments. The  tension  of  a  ligature  employed  for  this  purpose 
may  likewise  be  increased  if  used  in  combination  with  the 
rubber  wedge,  as  shown  in  Fig.  149.    The  reciprocal  form 

Fig.  149 


Correction  of  linguoversion. 

of  anchorage  should  be  employed  whenever  possible,  for  if  it 
is  neglected  at  the  outset  the  difficulties  occasioned  by  the 
adjoining  labio-  or  bucco versions  are  increased.  For  example, 
let  us  assume  that  we  neglect  such  an  opportunity  in  the 
case  shown  in  Fig.  150,  and  attempt  to  correct  the  linguo- 
version of  the  lateral  incisors  by  utilizing  the  stationary 
anchorage  of  the  molars.  Now,  a  more  detailed  considera- 
tion of  the  case  reveals  the  labioversion  of  the  central 
incisors.     But  suppose  we  had  completed  the  labial  move- 


196     TREATMENT  OF  MALPOSITION  OF  THE  TEETH 


ments  of  the  laterals  before  realizing  this  fact;  it  at  once 
becomes  clear  that  the  reduction  of  the  labioversion  of  the 
centrals  has  become  more  difficult.  Hence,  if  we  are  mind- 
ful of  our  advantages  in  advance,  we  can,  by  releasing  the 
nuts  mesial  to  the  buccal  tubes  (thus  allowing  the  alignment 
wire  to  rest  upon  the  labial  surfaces  of  the  centrals),  utilize 
reciprocal  anchorage. 


Fig.  150 


Reciprocal  anchorage  for  correction  of  linguoversion  and  labioversion. 

The  buccal  movement  of  molars  is  readily  accomplished 
by  utilizing  the  spring  temper  of  the  alignment  wire  (see 
Figs.  133  and  134).  Such  movements  may  be  required  on 
one  side  of  either  the  upper  or  lower,  or  on  both  sides,  and 
in  both  upper  and  lower  arches  simultaneously.  But  in 
either  event  the  movement  must  be  carefully  guarded  to 
prevent  undue  speed.  Should  it  proceed  too  rapidly,  it 
may  be  counteracted  by  reducing  the  expansion  pressure 


LINGUOVERSION  197 

of  the  wire  by  reversing  the  phers,  and  by  resorting  to  direct 
intermaxillary  anchorage,  as  shown  in  Fig.  151. 

To  prevent  undue  tipping  of  the  incisors  during  kibial 
movements,  it  frequently  becomes  necessary  to  adapt  the 
ahgnment  wire  close  to  the  gingival  line,  as  shown  in  Fig. 
153.  In  extreme  cases  a  modification  of  the  Case  contouring 
apparatus,  as  suggested  by  Korbitz,^  can  be  employed  (Fig. 
154).    Again,  unfavorable  tipping  may  assert  itself  in  rapid 

Fig.  151  Fig.  152 


Intermaxillary  anchorage  used  as  an  Increased  stretch  of  the  rubber  in  corn- 

auxiliary  in  case  of  unexpected  displace-  bination  with  alignment  wires  for  the 
ment  of  the  anchor  teeth.  correction  of  linguoversion   and  buccover- 

sion  of  molars.     (After  Reoch.) 

buccal  movements  of  the  molars,  and  thus  cause  extremely 
undesirable  difficulties  of  occlusion.  To  avoid  the  use  of 
the  direct  intermaxillary  anchorage  already  referred  to 
(which  is  annoying  to  the  patient),  and  in  anticipation  of 
such  undesirable  movements,  we  may  employ  the  square 
tubing  on  the  molar  bands,  as  suggested  by  Kemple.-  Vari- 
ous other  forms  of  molar  anchorage  for  this  purpose  have 

'  Kursus  der  Orthodontia.  ^  Proc.  Amer.  Soc.  Orthodontists,  1909. 


198     TREATMENT  OF  MALPOSITION  OF  THE  TEETH 

been  suggested  by  Barnes,  Hawley,  and  Ottolengui.^    These 
latter  forms  may  all  be  advantageously  employed  for  the 

Fig.  153 


High  adjustment  of  the  aUgnment  wire  to  prevent  tipping  of  the  incisors 
during  labial  movements. 

Fig.  154 


Korbitz's  modification  of  Case's  contouring  apparatus. 

bodily  buccal  movement  of  the  molars,  thereby  inducing 
desirable  lateral  development  in  the  osseous  structures, 
whenever  that  is  indicated. 


DISTOVERSION 


The  correction  of  a  distoversion  implies  a  mesial  move- 
ment within  the  line  of  the  arch.     One  of  the  simplest 


'  Proc.  Amer,  Soc.  Orthodontists,  1909. 


DISTOVERSION 


199 


instances  of  this  kind  is  shown  in  Fig.  155,  ilhistrating  the 
method  of  correcting  two  upper  centrals  in  distoversion  as 
a  result  of  an  abnormal  frenum  labium.  The  silk  ligature, 
owing  to  its  prolonged  tension  in  a  moist  environment,  is 
admirably  adapted  for  this  purpose.  Occasionally,  it  may 
be  advantageous  to  construct  a  plain  band  for  each  incisor. 


FiQ.  155 


For  mesial  movement  of  the  central  incisors. 
Fig.  156 


For  mesial  movement  of  the  central  incisors.    (After  Lukens.) 

with  a  labial  spur  (Fig.  156)  for  the  attachment  of  a  wire 
ligature,  which  is  applied  in  the  form  of  a  figure  eight. 
Such  ligatures  should  be  about  one  foot  long,  permitting  a 
firm  grasp  with  the  hands  while  twisting  their  knots.  The 
silk  ligature  already  referred  to  may  occasionally  be  carried 
beyond  the  centrals  and  include  the  laterals  and  cuspids. 


200      TREATMENT  OF  MALPOSITION  OF  THE  TEETH 

Small  spaces  between  the  six  anterior  teeth  in  either  jaw 
may  readil}-^  be  closed  in  this  manner.  The  skilful  use  of 
the  silk  ligature  is  an  important  detail  of  treatment,  even 
though  it  be  difficult  to  master. 

In  all  cases  where  the  separation  between  the  centrals  is 
very  marked  the  use  of  a  ligature  is  contraindicated.  Its 
hinge-like  attachment  favors  tipping  instead  of  bodily 
movement.  The  latter  can  be  accomplished  by  substituting 
the  screw  bolt  anchored  to  bands  by  means  of  tubes,  as 
shown  in  Fig.  157. 

Fig.  157 


For  bodily  mesial  movement  of  the  central  incisors.      (After  Lukens.) 

The  mesial  movement  of  bicuspids  may  also  be  affected 
by  ligatures  in  combination  with  notches  on  the  arch  (Fig. 
118).  After  all  mesial  movements  anterior  to  the  molars 
have  been  accomplished,  during  which  the  anchorage  was 
provided  by  these  teeth,  the  nuts  may  be  released  and  the 
molars  moved  mesially  if  indicated.  This  is  usually  best 
accomplished  by  means  of  intermaxillary  anchorage  (Fig.  122 
for  lowers,  and  Fig.  230  for  uppers). 


MESIOVERSION 


201 


MESIOVERSION 

Though  rarely  met  with  in  incisors,  and  only  occasionally 
in  cuspids,  it  is  frequently  found  affecting  bicuspids  and 
molars.  When  it  extends  to  the  anchor  teeth  the  difficulties 
of  treatment  are  considerably  increased.  A  single  anterior 
tooth,  such  as  a  central  or  lateral,  may  usually  be  moved 
distally  by  ligation  to  a  wire  provided  with  a  spur  in  a 
suitable  location.  Cuspids  only  slightl}'  in  mesioversion 
(which  are  almost  invariably  associated  with  linguoversion 
of  the  lateral  incisors)  are  readily  reduced  by  means  of  the 
rubber  wedge  (Fig.  147).  The  rubber  must,  in  such  instances, 
be  applied  toward  the  mesiolabial  angle.  In  extreme  mesio- 
version of  a  cuspid  the  latter  method  would  prove  inade- 
quate, hence  we  are  occasionally  compelled  to  employ  the 
traction  screw  (Figs.  158  and  159). 


Fig.  158 


Fig,   159 


Angle's  method  for  effecting  a  distal  movement  of  the  canine. 

Not  infrequentl}-,  owing  to  a  premature  loss  of  deciduous 
cuspids  and  first  molars,  the  first  bicuspids  erupt  mesial  to 
normal.  In  all  cases  where  other  treatment  is  in  progress 
during  such  a  period,  the  author  uses  the  method  shown  in 
Fig.  160.  The  illustration  shows  an  arm  extended  from  the 
alignment  wire  which  is  moved  distally  by  means  of  a  nut. 
The  arm  is  made  from  an  ordinary  tube  hook  and  prevented 


202     TREATMENT  OF  MALPOSITION  OF  THE  TEETH 

from  dropping  occliisally,  or  being  forced  gingivally,  by 
flattening  the  alignment  wire  with  a  file  along  its  lingual 
surface  and  subsequently  adapting  the  tube  to  it.  This 
appliance  is  also  applicable  in  the  correction  of  distoversion. 
Mesioversion  of  a  first  permanent  molar  may,  in  rare 
instances,  be  corrected  by  utilizing  all  of  the  anterior  teeth 
for  anchorage,  e.  g.,  where  the  second  deciduous  molar  was 


Fig.  160 


Author's  method  for  correcting  mesioversions  and  distoversions  of  bicuspids. 

lost  prematurely.  The  combined  resistance  of  the  anterior 
teeth,  after  secure  ligation  to  the  alignment  wire,  may  thus 
be  pitted  against  the  first  molar  by  turning  distally  the  nut 
in  front  of  the  tube.  Finally,  the  distal  movement  of  the 
anchor  teeth  can  be  accomplished  by  use  of  intermaxillary 
anchorage — as  in  mesioclusion,  and  in  cases  of  distoclusion — 
and  in  rare  instances  by  means  of  extramaxillary  anchorage. 
These  are  described  in  subsequent  chapters. 


CHAPTER    XIV 

TREATMENT  OF  MALPOSITION  (Continued) 
TORSOVERSION 

This  is  a  very  common  form  of  malposition,  and  its 
treatment  dates  back  to  Delabarre^  (1815),  who  used  a 
lever  for  its  correction,  and  Linderer  (1834)  and  Schange 
(1841),  who  accomplished  the  same  end  with  the  ligature. 
The  lever  was  also  employed  by  Linderer,  and  has  recently 
been  revived,  in  a  somewhat  modified  form,  by  Angle.^ 
Its  use  is,  however,  rarely  indicated,  because  it  possesses  a 
distinct  disadvantage  in  that  it  causes  an  outward  move- 
ment, as  well  as  rotary  action.^  Furthermore,  the  mere 
fact  that  we  rarely  have  to  deal  with  malposition  of  only  one 
tooth  compels  us  to  employ  other  mechanisms;  hence  the 
alignment  wire,  with  its  limitless  possibilities,  again  merits 
our  attention. 

On  the  other  hand,  the  principle  of  the  le\'er  is  still  worthy 
of  our  consideration,  especially  in  a  restricted  or  localized 
sense.  It  is  well  known  that  a  corrected  torsoversion  is 
hard  to  maintain  in  a  normal  relation,  and  it  is  in  such 
instances  that  the  modified  lever  plays  an  important  role. 
The  retainer  of  a  torsoversion  frequently  embodies  a  spur 
of  wire,  which  can  be  pressed  into  service  should  a  tendency 

1  Pfaff,  Lehrbuch  der  Orthodontie. 

2  Proc.  Int.  Med.  Congress,  Washington,  18S7. 

3  See  Korbitz,  Kursus  der  Orthodontie. 


204 


TREATMENT  OF  MALPOSITION 


toward  a  former  malposition  assert  itself.  Fig.  161  shows  an 
application  of  this  principle  during  the  retention  period. 
Korbitz^  has  recently  suggested  a  modification  of  it  for  the 
treatment  of  a  simple  torso  version,  provided  the  necessary 
space  can  be  gained  by  the  purely  local  action  (Fig.  162). 
He  maintains  that  the  rubber  elastic  shown  in  the  illustration 
exerts  the  necessary  sideward,  or  separating,  action.  The 
tube  attachment  of  the  lever  provides  a  hinge-joint,  which 
permits  the  rotary  movement. 


Fig.  161 


Fig.  162 


For  effecting  slight  rotary  movements. 


Hinge  appliance  for  rotation.     (After 
Korbitz.) 


The  roots  of  bicuspids  present  oblong  forms  on  cross- 
section,  and  offer  considerable  resistance  to  a  rotary  move- 
ment. It  occasionally  becomes  necessary,  therefore,  to 
apply  extreme  measures  to  accomplish  the  desired  results. 
Fig.  163  shows  a  case  of  this  kind  from  the  collection  of  Dr. 
Lukens,  and  exhibits  the  pushing  action  of  a  jack-screw 
on  the  buccal  side,  and  the  pulling  action  of  a  rubber  ring 
on  the  lingual. 


'  See  Korbitz,  Kursus  der  Orthodontie. 


TOKSOVERSION 


205 


In  rare  instances,  the  molars  will  require  rotation,  and,  if 
confined  to  the  anchor  teeth,  this  can  readily  be  accom- 
plished with  the  ends  of  the  alignment  arch  (Figs.  131  and 
132).  Should  the  second  molar  be  in  torsoversion,  the 
draught  of  an  elastic  ring  can  be  called  into  service  after 
the  manner  suggested  by  Korbitz^  (Fig.  164). 


Fig.  163 


Forcible  correction  of  torsoversion  of  a  bicuspid.     (After  Lukens.) 

The  rotation  of  incisors,  cuspids,  and  bicuspids  can 
generally  be  affected  by  means  of  the  ligature,  and  we  now 
pass  to  the  details  of  its  application.     Fig.  165  shows  the 


Kursus  der  Orthodontic. 


206 


TREATMENT  OF  MALPOSITION 


application  of  a  silk  ligature  for  the  correction  of  a  simple 
torsoversion  in  an  upper  central  incisor,  the  ligature  being 
applied  in  the  form  of  a  loop.    Fig.  166  shows  the  applica- 


FiG.  164 


Correction  of  torsoversion  in  the  second  molar.    (After  Korbitz.) 
Fig.  165 


The  silk  ligature  applied  for  correction  of  torsoversion  in  an  upper  central. 
Fig.  166 


The  silk  ligature  applied  for  reciprocal  action  in  correcting  lower  centrals  in 
torsoversion.     (After  Korbitz.) 

tion  of  a  silk  ligature  to  the  lower  central  incisors.  In  all 
cases  where  the  lower  centrals  are  of  sufficient  length  and 
of  favorable  form,  this  method  will  prove  efficacious. 


TORSOVERSION 


207 


Both  upper  and  lower  cuspids,  owing  to  their  unfavorable 
form,  usually  require  the  use  of  bands  and  spurs  to  prevent 
the  ligatures  from  slipping  and  from  becoming  disengaged. 


Fig.  167 


For  torsoversion  in  upper  cuspids. 
Fig.  168 


For  torsoversion  in  bicuspids. 


208  TREATMENT  OF  MALPOSITION 

Fig.  167  illustrates  two  ways  of  treatment  for  torsoversion 
in  upper  cuspids,  by  means  of  a  ligature  in  combination 
with  the  rubber  wedge.  The  wire  ligature  is  preferable  to 
the  silk  ligature  in  the  rotation  of  cuspids,  and  can  be 
rendered  more  certain  and  prolonged  in  its  action  when 
combined  with  the  rubber. 

The  rotation  of  a  bicuspid  is  shown  in  Fig.  168.  In  A, 
the  rotation  is  accomplished  by  means  of  a  ligature  in  com- 
bination with  the  rubber  wedge;  in  B,  a  buccal  movement 
is  also  indicated,  hence  the  ligature  only  is  used.  The 
rubber  wedge  is  not  only  inapphcable  in  such  a  case,  but 
contraindicated  in  the  first  stages. 

INFRAVERSION 

As  suggested  by  Korbitz,^  this  form  of  malposition  may 
be  either  relative  or  absolute.  A  tooth  is  relatively  too  short 
when  its  crown  is  fully  exposed  and  alveolar  development 
has  been  arrested.  A  tooth  is  absolutely  too  short  when 
its  crown  is  not  fully  exposed  and  alveolar  development 
apparently  normal. 

Fig.  169 


For  absolute  infraversion  in  a  central  incisor. 


The  correction  of  infraversion  is  usually  accomplished 
with  the  alignment  wire  and  stationary,  reciprocal,  or 
intermaxillary  anchorage.  Fig.  169  shows  a  case  of  absolute 
infraversion  of  an  upper  central  which  is  being  elongated  by 


1  Kursus  der  Ortbodontie. 


INFRAVERSION 


209 


means  of  the  ligature  fastened  to  the  ahgnment  wire.  Tlie 
adjoining  teeth  are  securely  ligatured  to  the  wire,  after 
which  the  ligature  to  the  malposed  central  is  applied  high 
toward  the  neck,  and  then  to  the  wire.  The  silk  ligature 
is  preferable  in  such  instances,  and  should  invariably  be 
passed  above  the  cervical  ridge  of  enamel.  In  lateral  incisors 
and  cuspids  it  frequently  becomes  necessary  to  adjust  bands 
with  spurs  to  prevent  the  ligatures  from  slipping. 

In  cases  of  relative  infraversion,  as,  for  instance,  in  the 
so-called  "open  bite,"  the  spring  temper  of  the  alignment 
wire  is  utilized.    The  wire  is  inserted  in  such  a  manner  that 


Fig.  170 


For  relative  infraversion  of  the  incisors. 

it  approaches  the  incisal  edges  of  the  teeth  to  be  elongated, 
and  during  the  process  of  ligation  is  held  well  toward  the 
gingival  line,  antil  the  ligatures  of  all  the  teeth  to  be  elon- 
gated have  been  attached.  Upon  being  released,  its  tendency 
will  be  toward  its  original  position,  thus  forcing  the  elonga- 
tion of  the  teeth  fastened  to  it  (Fig.  170).  It  must  not  be 
overlooked,  however,  that  such  action  might  also  cause  a 
mesial  tilting  of  the  molars;  hence  a  more  secure  form  of 
stationary  anchorage  is  occasionally  indicated,  as  shown  in 
the  illustration.  An  additional  anchor  band  is  provided  for 
the  second  bicuspid,  and  the  buccal  tube  soldered  to  both. 
Such  precaution  renders  the  anchorage  more  secure. 
14 


210 


TREATMENT  OF  MALPOSITION 


Intermaxillary  anchorage  may  be  used  in  either  its 
stationary  or  reciprocal  form,  depending  upon  the  require- 
ments of  the  case.  If  the  teeth  of  one  arch  only  are  to  be 
elongated,  the  alignment  wire  in  the  opposing  jaw  is  securely 
attached  to  many  teeth;  and  only  to  two  or  four  in  the  arch 
to  be  treated.  On  the  other  hand,  in  cases  Adhere  the  teeth 
of  both  arches  are  to  be  lengthened,  we  can  advantageously 
employ    reciprocal    intermaxillary    anchorage    (Fig,    171). 

Fig.  171 


miiiiiiiiiimiiiiinmmimiiiimiiiin'f^ 


^iiiwinmimnuiimiiwiimiirnip^l 


Direct  intermaxillary  anchorage  for  infraversion. 

The  elongation  of  molars  can  also  be  effected  by  means  of 
intermaxillary  anchorage,  either  by  direct  stationary,  or 
the  reciprocal  form.    (Compare  Figs.  173  and  200.) 


SUPRA  VERSION 


Though  supraversion  is  by  many  regarded  as  a  common 
form  of  malposition,  other  writers  maintain  that  it  is 
extremely  rare.  The  latter  assert  that  supraversion  is  more 
apparent  than  real;  that,  in  most  instances,  we  have  to  deal 
with  infraversion  in  more  remote  places  in  the  arches.  For 
example,  the  cases  shown  in  Figs.  37  and  38  are  said  to 
exhibit  only  an  apparent  supraversion  of  the  incisors;  the 


SUPRAVERSION 


211 


real  difficulty — so  some  writers  believe — is  an  infraversion 
of  the  bicuspids  and  molars.^ 

The  correction  of  supraversion  is  extremely  difficult,  and' 
can  only  be  executed  to  a  very  limited  extent.  Occasionally, 
such  action  can  be  procured  with  the  alignment  wire  and 
ligatures,  as  shown  in  Fig.  172.    The  wire  is  inserted  into 

Fig.  172 


Ligature  applied  for  reduction  of  supraversion  in  upper  centrals. 


Fig.  173 


^^nnzmznznzL 


The  reduction  of  supraversion  in  lower  incisors  intensified  by  means  of  inter- 
maxillary elastics. 

buccal  tubes  whose  mesial  ends  point  gingivally.  It  is  thus 
brought  close  to  the  gingival  line,  and  the  ligature,  being 
passed  around  the  teeth  toward  their  incisal  edges,  is  tied 
while  the  wire  is  pulled  incisally.  Its  spring  causes  it  to 
return  toward  the  gingival  line,  thus  carrying  the  attached 
teeth  with  it. 

Lower  incisors  can  be  shortened  in  similar  fashion;  and 


'  Rogers,  Items  of  Interest,  January,  1911. 


212  TREATMENT  OF  MALPOSITION 

where  the  intermaxillary  anchorage  is  employed  simulta- 
neously (which  is  frequently  the  case  in  distoclusion)  the 
action  can  be  intensified  (Fig.  173). 

The  opposite  application  of  the  intermaxillary,  e.  g.,  in 
mesioclusion,  can  also  be  utilized,  though  mesioclusions 
rarely  present  supraversion  of  the  upper  incisors.  It  is 
important  to  remember  that  in  the  application  of  a  ligature 
for  a  shortening  action,  we  must  adjust  it  well  toward  the 
incisal  edge,  i.  e.,  above  the  neck;  and  that  such  action  is  not 
obtainable  in  bicuspids.  Owing  to  their  unfavorable  forms, 
being  cone-like,  they  invariably  require  the  use  of  bands 
with  spurs,  to  prevent  the  slipping  of  ligatures. 

PERVERSION  AND  TRANS  VERSION 

These  two  forms  are,  fortunately,  extremely  rare  (par- 
ticularly the  latter),  and  our  means  for  their  correction  even 
more  limited  than  in  the  case  of  supraversion.  For  trans- 
version  there  are,  practically,  no  methods  at  our  command; 
though  theoretically,  transplantation  suggests  itself.  Per- 
version, on  the  other  hand,  is  so  often  combined  with  linguo- 
or  labioversion  that  it  is  frequently  operable.  Fig.  120 
shows  the  most  common  form  met  with,  and  one  of  the 
best  methods  yet  devised  for  its  correction. 


CHAPTER    XV 

TREATMENT  OF  NEUTROCLUSION 

SIMPLE  NEUTROCLUSION 

As  intimated  in  Chapter  XIII,  the  treatment  of  a  mal- 
occlusion may  embrace  the  correction  of  (a)  tooth  position, 
(b)  arch  form,  (c)  arch  relation,  and,  conjointly,  jaw  and 
face  deformity;  and  though  each  of  these  details  is  worthy 
of  separate  consideration,  it  is  obvious  that  the  goal  can  best 
be  reached  by  the  establishment  of  normal  occlusion.  This 
implies  that  each  case  be  considered  in  its  entirety,  that  all 
its  various  problems  receive  contemporaneous  treatment. 
Hence  we  pass  to  a  consideration  of  the  various  types. 

As  elsewhere  noted,  most  malocclusions  develop  slowly; 
in  their  early  stages  all  are  comparatively  simple.  We  shall 
begin,  therefore,  with  a  few  of  the  simpler  forms. 

Case  A. — A  robust  girl,  aged  eight  years  (Figs.  174  and 
175);  the  illustrations  presenting  side  and  occlusal  views 
before  and  after  treatment.  The  history  of  the  case  is 
entirely  negative;  the  temporary  teeth  have  never  been 
affected  by  caries,  having  received  regular  dental  attention. 
The  mother  of  the  patient  believes  in  exercising  every 
precaution,  and  has  had  the  nose  and  throat  examined  by  a 
rhinologist,  who  found  them  normal.  Infancy  was  unevent- 
ful, being  free  from  any  of  the  serious  infectious  diseases 
of  that  period  of  life.  The  family  history  is  also  negative, 
both  parents  having  normal  dentures;  hence  the  question 
of  cause  remains  obscure. 


214 


TREATMENT  OF  NEUTROCLUSION 


Formerly  it  was  common  practice  to  postpone  treatment 
in  such  cases  until  after  the  eruption  of  bicuspids  and 
cuspids,  for  it  was  deemed  impracticable,  if  not  unwise,  to 


Fig.  174 


Right  and  left  views  of  denture  before  and  after  treatment.    (Compare  with 
Fig.  175.) 

move  their  temporary  predecessors.  A  moment's  com- 
parison of  the  models  readily  establishes  the  conclusion  that 
it  is  good  practice  to  administer  treatment  thus  early.  It 
is,  of  course,  true  that  the  denture  of  this  child  will  require 


SIMPLE  NEUTROCLUSION 


215 


■further  observation,  and  probably  treatment,  depending  on 
the  subsequent  normal  or  abnormal  eruption  of  the  now 
unerupted  teeth.  But  it  is  obvious  that  the  enlargement 
of  the  dental  arches  has  greatly  increased  the  probability 
of  their  normal  eruption.  And  further,  it  must  be  equally 
clear  that  the  malocclusion  already  existing  in  the  incisors 
wdll  never  correct  itself,  no  matter  how  long  the  treatment 
is  postponed. 


Fig. 

175 

^liyv^^^^M 

^^^k    ^  r  ^'^^B 

Occlusal  views  before  and  after  treatment  of  denture  shown  in  Fig.  174. 

Again,  the  treatment  of  this  denture  did  not  constitute 
a  hardship,  and  was  no  reason  for  its  postponement.  The 
appliances  used  consisted  of  four  adjustable  anchor  bands 
for  the  first  permanent  molars  (Fig.  113),  and  applied  after 
the  manner  indicated  in  Fig.  112,  though  spurred  bands 
at  the  mesial  ends  of  the  extension  wires  were  considered 
unnecessary.  The  ends  of  the  extension  wires,  after  being 
cut  to  exact  length,  were  bent  at  sharp  right  angles  to 


216  TREATMENT  OF  NEUTROCLUSION 

engage  silk  ligatures  tied  to  the  alignment  wires.  The  move- 
ment of  the  right  upper  central  incisor  was  also  effected  with 
a  silk  ligature,  which  was  renewed  at  weekly  intervals.  The 
entire  treatment  consumed  less  than  four  months. 

Maintenance  of  the  corrected  condition  is  now  being 
provided  by  an  appliance  on  the  lower  arch  similar  in  design 
to  that  shown  in  Fig.  140,  though  it  is  anchored  to  the 
second  temporary  molars.     Bands  with  spurs  for  the  pre- 

FiG.  176 


Modification  of  appliance  as  advocated  by  Korbitz. 

vention  of  anterior  displacement  were  placed  upon  the 
lateral  incisors,  instead  of  the  canines  as  illustrated.  In  the 
upper  arch  maintenance  is  largely  provided  by  the  occlusion 
of  the  lower,  and  by  a  plain  band  with  spurs  upon  the  left 
central  after  the  manner  indicated  in  Fig.  135, 

An  ingenious  and  very  excellent  modification  of  this  plan 
of   treatment   has   recently   been   advocated   by   Korbitz' 


1  Zeitschr.  f.  Zahnarztl.  Orthopadie,  September,  1910;  Deutsch.  Monatssch.  f.  Zahn- 
heilk.,  November,  1910. 


SIMPLE  NEUTROCLUSION 


217 


(Fig.  176).  He  uses  the  hinge-joint  at  (a),  which  is  procured 
by  soldering  an  IS-gauge  tube  to  the  free  end  of  the  clamping 
bolt,  which  thus  removes  all  possibility  of  rotation  of  the 
molars.    He  further  advocates  anchorage  of  the  mesial  end 


Fig. 

177 

H 

■ 

1 

■ 

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WP 

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^^a 

ii^^ 

1 

^^IHh 

■ 

Side  views  of  case,  aged  nine  years,  before  and  after  treatment.     (Compare 
with  Fig.  178.) 

of  the  lingual  wire  to  a  canine  band,  to  which  he  solders 
another  such  tube  (6)  at  right  angles.  The  latter  is  in  anti- 
cipation of  retention,  when  it  will  cany  an  18-gauge  section 
of  wire  extending  to  its  fellow  on  the  opposite  side,  thus 


218 


TREATMENT  OF  NEUTROCLUSION 


maintaining  the  newly  established  arch  width.  The  buccal 
movement  of  the  temporary  teeth  is  accomplished  with  an 
elastic  rubber  band  attached  to  a  hook  on  the  gingivolabial 
border  of  the  canine  band,  then  passes  over  a  tube  hook  on 
the  alignment  wire,  and  on  to  the  anchor  band,  all  as  shown 
in  the  illustration.  The  form  given  to  the  alignment  wire 
controls  the  ultimate  form  of  the  dental  arch. 


Fig.  178 


Occlusal  views  of  case  shown  in  Fig.- 177. 

Case  B.— An  anemic  girl,  aged  nine  years  (Figs.  177  and 
178),  who  related  a  history  which  gave  no  clue  as  to  the 
probable  cause.  Indeed,  such  local  arrests  of  development 
as  the  denture  of  this  child  exhibits  are  difficult  to  account 
for.  The  linguoversion  of  the  incisors  could  hardly  be  the 
result  of  premature  loss  of  the  temporary  cuspids;  the  mouth 
presented  an  unusually  healthy  condition  in  every  other 
respect,  being  immune  to  caries.    Though  the  canines  have 


SIMPLE  NEUTROCLUSION 


219 


been  exfoliated,  it  would  be  interesting  to  learn  the  cause 
of  their  early  loss,  which  might  then  serve  as  causa  prima. 

The  plan  of  treatment  was,  in  many  respects,  similar  to 
that  outlined  for  Case  A,  though  the  incisors  were  differently 
malposed  and  necessitated  a  slight  change  in  the  details. 
It  is  evident  that  both  arches  required  expansion,  and  that 
all  incisors  be  moved  labially.  The  upper  incisors  are  also 
in  distoversion,  with  wide  spaces  between  them. 


Fig.  179 


Maintenance  appliances  used  for  the  case  shown  in  Figs.  177  and  178. 


The  appliance  consisted  of  four  molar  anchor  bands  with 
extension  wires,  two  IS-gauge  alignment  wires,  and  four  plain 
bands  with  spurs  for  the  lateral  incisors.    The  expansion  of 


220 


TREATMENT  OF  NEUTROCLUSION 


each  arch  is  very  noticeable  in  the  after  treatment  models, 

and  resulted  in  gaining  the  necessary  spaces  for  the  cuspids. 

Maintenance  of  the  corrected  condition  was  provided  by 

the  appliance  shown  in  Fig.  179.    The  bands  upon  the  lateral 


Fig.  180 


Side  views  of  case,  aged  eleven  years,  before  and  after  treatment. 

incisors  are  the  same  as  those  used  for  movement;  and  the 
anchor  bands  upon  the  molars  are  reduced  in  parts  by 
removal  of  the  buccal  tubes  and  clamping  bolts,  after  which 


SIMPLE  NEUTROCLUSION 


221 


the  free  lapping  ends  are  united  with  solder  to  form  a  con- 
tinuous band  of  exact  size. 

Case  C. — A  boy,  aged  eleven  years  (Figs.  180  and  181), 
who  has  suffered  much  from  dental  caries,  and  to  whom 
mastication  has  for  years  been  both  difficult  and  painful. 
His  mother  related  an  operation  for  hypertrophy  of  the 
tonsils  performed  during  his  ninth  year.     Thus  it  is  very 


Fig.  181 


Occlusal  views  of  case  shown  in  Fig.  ISO. 

probable  that  the  arrest  of  development  in  the  upper  arch 
is  a  result  of  the  ailments  just  enumerated. 

The  treatment  was  again  similar  in  plan  to  that  described 
for  Cases  A  and  B,  though  the  lower  canines  were  also 
involved.  Hence  they  are  included  in  the  treatment  by 
providing  them  with,  spurred  bands  as  already  described. 
]\Iost  of  the  temporary  teeth  remaining  are  so  badly  decayed 
that  their  immediate  removal  is  indicated.     By  means  of 


222 


TREATMENT  OF  NEUTROCLUSION 


the  anchor  bands,  16-gauge  alignment  wires  and  ligatures, 
with  all  of  which  the  reader  is  now  somewhat  familiar, 
expansion  of  both  arches  was  achieved  as  shown  in  the 
models. 


Fig.  182 


Facial  relations  before  and  after  treatment  of  case  shown  in  Figs.  180  and  181. 

Maintenance  was  provided  for  the  upper  arch  by  an 
appliance  as  shown  in  Fig.  179,  and  for  the  lower  by"one  like 
Fig.  140. 


SIMPLE  NEUTROCLUSION  223 

Fig.  182  shows  the  facial  relations  before  and  after  treat- 
ment. 

Case  D. — A  boy,  aged  nine  years  (Figs.  183  and  184), 
slightly  below  the   average  in  height.      Inquiry   into  his 

Fig.  183 


Side  views  before  and  after  treatment  of  case,  aged  nine  years.    Note  the 
lingual  relation  of  the  entire  right  upper  lateral  half. 

history  revealed  the  fact  that  his  persistent  mouth  breathing 
and  noticeable  facial  deformity  had  led  his  mother  to  con- 
sult a  rhinologist,  who  removed  an  adenoid  and  enlarged 


224 


TREATMENT  OF  NEUTROCLUSION 


tonsils  about  six  months  previously.  His  father,  whom  he 
resembles  in  facial  expression,  hair,  and  eye  color,  has  a 
malocclusion  of  the  same  type,  which  is  comparatively  rare. 
The  arches  are  in  normal  mesiodistal  relation,  though  the 
entire  right  upper  lateral  half  is  lingual  to  the  lower.  The 
lower  arch  is  of  ideal  form,  and  was  not  involved  in  the 


Fig.  184 


Front  and  occlusal  views  of  case  shown  in  Fig.  183. 

treatment.  But  the  upper  arch  presents  a  feature  that  is 
interesting  in  its  anchorage  requirements.  Only  one  lateral 
half  requires  a  buccal  movement,  though  the  expanding 
action  of  the  alignment  wire  acts  with  equal  pressure  (as 
ordinarily  applied)  upon  both  sides.  Let  us  briefly  consider 
its  various  methods  of  application,  and  of  this  controlled 
action  in  particular.    Fig.  185  is  diagrammatic  of  the  action 


SIMPLE  NEUTROCLUSION 


225 


of  the  alignment  wire  in  the  various  ways  in  which  it  is 
ordinarily  appHed.  In  a  the  dotted  hnes  indicate  its  expan- 
sive power  toward  the  buccal  in  each  lateral  half,  when 
introduced  with  that  intent.  Under  such  circumstances  it 
also  tends  to  glide  distally  within  the  tubes,  resulting  in  a 
lingual  movement  of  the  incisors,  as  shown  by  the  arrows, 
unless  such  action  is  prevented  by  contact  of  the  nuts  against 

FiQ.  185 


Shows  the  action  of  the  alignment  wire  in  its  various  applications. 


the  mesial  ends  of  the  buccal  tubes.  If  applied  for  con- 
traction of  the  arch,  as  in  b,  its  tendency  in  the  incisal  area 
will  be  in  a  labial  direction,  as  indicated  in  the  drawing. 
In  c  the  distribution  of  the  load  on  the  molars  imposed  by 
the  tension  on  the  bicuspids  is  shown. 

The   case   under   discussion   requires   that   the   bilateral 
buccal  action  of  the  alignment  wire  as  shown  in  a,  Fig.  185, 
15 


226  TREATMENT  OF  NEUTROCLUSION 

be  rendered  unilateral.  This  can  readily  be  accomplished 
if  the  anchorage  of  the  wire  in  the  tube  on  the  normal  side 
is  changed  to  complete  stationary  form.  By  soldering  a 
buccal  tube  to  the  left  anchor  band,  as  shown  in  Fig.  186, 
and  by  providing  it  with  a  lingual  extension  wire  as  already 
described,  the  resistance  was  so  increased  as  to  effectually 
overcome  the  expanding  action  of  the  wire  on  the  normal 
side.  Its  effect,  therefore,  was  to  move  the  right  molar 
buccally,  w^hich  occurred  within  a  month's  time.  The 
expansion  action  of  the  wire  was  now  slightly  reduced  by 
bending  with  the  pliers,  and  after  re-insertion  the  second 
temporary  molar  was  attached.  The  buccal  movement  of 
this  tooth,  and  of  its  neighbors  to  the  mesial,  was  accom- 
plished by  means  of  ligatures. 

FiQ.  186 


Maintenance  was  easily  provided  by  an  appliance  con- 
sisting of  two  molar  anchor  bands  with  lingual  connecting 
wire,  as  shown  in  Fig.  179,  though  its  anterior  section  was 
held  in  place  by  spurred  bands  upon  the  centrals.  These 
bands  were  also  united  with  solder  at  their  mesial  contact 
points,  thus  combining  their  resistance  and  providing 
maintenance  for  the  corrected  infraversion  of  the  right 
central. 

COMPLEX  NEUTROCLUSION 

Cases  belonging  to  this  group  differ  from  the  foregoing 
only  in  their  minor  symptoms,  being  identical  in  the  funda- 


COMPLEX  NEUTROCLUSION  227 

mental  characteristic,  viz.,  the  normal  mesiodistal  relation 
of  the  lower  arch  to  the  upper.  They  are  usually  older, 
however,  consequently  more  teeth  are  involved,  and  their 


Fig. 

187 

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1 

I^T^^T^^' "^"^ 

J 

■■HH 

Side  views  before  and  after  treatment  of  case,  aged  thirteen  years. 

various  features  are  usually  emphasized  in  the  terminolog\' 
by  the  addition  of  qualifying  phrases.  The  division  is, 
therefore,  purely  arbitrary. 


228 


TREATMENT  OF  NEUTROCLUSION 


Case  "E.—  Neutroclusion  complicated  by  pronounced  linguo- 
version  of  the  upper  incisors  and  infraversion  of  the  upper 
cuspids.  A  strong,  healthy  girl,  aged  thirteen  years  (Figs.  187 
and  188),  whose  non-resonant  voice  and  marred  facial 
expression  before  treatment  (Fig.  189)  were  symptomatic  of 
arrest  of  development  of  the  intermaxillary  bone  and  nasal 
passages,  was  requested  to  consult  a  rhinologist.    The  exami- 


Fig. 

188 

^,^-«.^^^                    ' 

agg-^ 

J, 

B>|a- 

dt'^'^Mi^i 

^wMS^^^C^^^^^^B 

m^i 

m- 

^^iv 

■P^^g 

HB^l^^l 

c 

^ 

^^^Hl'^E^ffil 

pw 

"1   '  \i^rzjM^^M 

^^F^^^^^i^^m^^ 

WF 

•."Hr^- 

^^L '  'J,  \^^^^ 

^ 

r/xtii^Sy^^M 

Occlusal  views  of  case  shown  in  Fig.  187. 

nation  revealed  the  presence  of  adenoids  in  the  nasopharynx 
and  hypertrophy  of  the  inferior  turbinates.  After  removal 
of  this  hypertrophied  tissue  by  the  rhinologist,  the  treatment 
of  the  malocclusion  was  begun. 

The  appliances  consisted  of  four  molar  anchor  bands 
with  buccal  tubes;  plain  bands  with  spurs  on  the  disto- 
gingival  border  of  their  lingual  surfaces  for  the  upper  lateral 


COMPLEX  NEUTROCLUSION 


229 


incisors  and  lower  cuspids;  and  two  16-gauge  alignment  wires. 
The  molar  bands  were  of  a  design  as  shown  in  Fig.  113. 


Fig.  189 


Facial  relations  before  and  after  treatment  of  case  shown  in  Figs.  187  and  188. 

The  adjustment  of  the  entire  appliance  consumed  six  short 
semiweekly  visits,  after  which  tension  was  applied.  The 
alignment  wires  were  given  a  slight  expansive  spring;  the 


230  TREATMENT  OF  NEUTROCLUSION 

extension  wires  were  fastened  to  the  alignment  wire  after 
the  manner  indicated  in  Fig.  112,  and  hgatures  appHed  to 
the  lower  incisors  and  two  upper  centrals.  After  a  period 
of  three  weeks  considerable  movement  had  been  gained, 
which  in  a  measure  liberated  the  interlocked  upper  laterals. 
Ligatures  were  now  applied  to  these  teeth,  as  well  as  to  the 
lower  cuspids.  After  another  period  of  four  weeks  sufficient 
movement  had  been  accomplished  to  permit  of  a  more 
favorable  adjustment  of  the  upper  alignment  wire.  By 
careful  bending  after  the  manner  indicated  in  Fig.  130,  it 
was  possible  to  carry  it  sufficiently  to  the  gingival  line,  so 
that  it  embraced  the  seemingly  prominent  canines.  Its 
length  was  so  adjusted  that  it  rested  firmly  upon  their  labial 
eminences,  thus  relieving  the  strain  upon  the  upper  molars, 
and  aiding  materially  in  reducing  the  developing  supra- 
version  of  the  upper  laterals,  which  was  now  asserting  itself. 
It  may  be  worthy  of  mention  to  state  that  the  second  upper 
temporary  molars  were  extracted  during  the  patient's 
second  visit,  which  resulted  in  the  immediate  eruption  of 
their  successors. 

Maintenance  has  been  sustained  by  an  appliance  for  the 
upper  arch,  as  shown  in  Fig.  179  (upper  diagram),  and  for 
the  lower  as  shown  in  Fig.  140.  The  improved  facial  lines 
resulting  from  the  treatment  are  shown  in  Fig.  189. 

Case  F. —  Neutroclusion  complicated  by  extreme  lahioversion 
of  the  upper  incisors.  A  boy,  aged  nine  years  (Figs.  190  and 
191),  addicted  to  the  habit  of  sucking  his  lower  lip.  Several 
acute  attacks  of  rhinitis  a  year  previous  had  led  the  mother 
to  consult  a  rhinologist,  who  failed  to  detect  any  lymphoid 
hyperplasia  in  the  nasopharynx.  And  though  the  deformity 
is  typical  of  an  adenoid  child,  we  are  thus  forced  to  conclude 
that  the  habit  already  alluded  to  is  the  sole  cause  of  the 


COMPLEX  NEUTROCLUSION  231 

malocclusion.     The  facial  deformity  in  this  instance  was 
very  marked,  presenting  an  enlarged  lower  lip. 

Treatment  was  executed  by  the  use  of  appliances  identical 
with  those  employed  for  the  previous  cases,  with  addition 

Fig.  190 


Side  views  of  Case  F,  before  and  after  treatment. 

of  two  tube  hooks  on  the  upper  alignment  wire.  These 
were  soldered  at  points  opposite  the  interproximal  spaces 
between  laterals  and  cuspids.    Rubber  elastics  were  anchored 


232 


TREATMENT  OF  NEUTROCLUSION 


after  the  manner  indicated  in  Fig.  122,  after  which  the 
nuts  on  the  upper  ahgnment  wire  were  released.  This  action 
resulted  in  a  lingual  movement  of  the  upper  incisors.  In 
the  meantime  the  lower  arch  was  liberally  expanded  over  its 
entire  length,  and  the  upper  temporary  cuspids  and  molars 
moved  buccally. 

Fig.  191 


Occlusal  views  of  case  shown  in  Fig.  190. 

Post-treatment  maintenance  is  being  effectually  supplied 
by  an  appliance  similar  to  that  shown  in  Fig.  127,  which 
provides  for  a  continuation  of  the  intermaxillary  elastics. 
There  being  no  permanent  cuspids  to  anchor  to  in  the  upper 
arch,  the  hooks  were  in  the  nature  of  an  extended  arm  from 
the  two  central  bands  (Fig.  214). 

Case  G. —  Neutroclusion  complicated  by  labioversion  of 
2,  I  1,  2,  and  perversion  of  1  \  .     A  girl,  aged  twelve  years 


COMPLEX  NEUTROCLUSION 


233 


(Figs.  192  and  193),  whose  "prominent"  upper  incisors  and 
consequent  facial  deformity  led  her  parents  to  a  consultation. 
They  also  felt  certain  that  the  delayed  eruption  of  the  right 
upper  central  was  abnormal.  A  hard  mass  could  plainly 
be  felt  at  this  point,  Fig.  192,  which  gave  assurance  to 
the  belief  that  the  tooth  was  impacted.     The  father  then 


Fig.  192 


Side  and  front  views  of  Case  G,  before  and  after  treatment. 


related  the  following  history:  He  had  a  similar  "space" 
on  his  left  upper  side,  and  during  his  seventeenth  year  two 
teeth  erupted  simultaneously,  one  considerably  lingual  to 
normal.  Upon  examination,  his  left  central  was  found 
in  labioversion,  and  he  stated  that  the  "extra  tooth"  was 


234 


TREATMENT  OF  NEUTROCLUSION 


extracted  shortly  after  its  appearance.  The  mother  presented 
a  normal  denture.  Models  of  the  father's  teeth  were  now 
constructed,  and  a  radiograph  ajdvised  for  the  daughter, 
with  the  result  shown  in  Fig.  12.  This  clearly  revealed  the 
presence  of  a  supernumerary  tooth,  though  on  the  opposite 
side  to  that  of  the  father.  After  the  construction  of  his 
models  he  was  asked  to  locate,  as  nearly  as  possible,  the 


Fig. 

193 

^^^^F'iwi^M 

iL^ill^^Mi^.^ 

.-— ^ 

iKlZi  "^H 

J.'S^^'^M 

^H^^wj'^fl 

liii 

mm^ 

Occlusal  views  of  case  shown  in  Fig.  192. 


point  at  which  his  "extra  tooth"  erupted.  He  marked  same 
with  a  pencil  at  a  point  opposite  to  that  shown  in  Fig. 
193.  An  anesthetic  was  now  administered  to  the  daughter, 
an  incision  made,  and  the  supernumerary  tooth  removed. 
After  a  week's  delay,  during  which  the  wound  had  completely 
healed,  the  appliances  were  adjusted. 

Treatment  of  the  malocclusion  was  practically  identical 


COMPLEX  NEUTROCLUSION 


235 


with  tha,t  provided  for  Case  F,  except  that  it  included  the 
extraction  of  all  remaining  temporary  teeth,  which  the  age 
of  the  patient  justified.  After  several  weeks  of  treatment 
the  impacted  tooth  made  its  appearance.  This  was  treated 
by  means  of  a  plain  band  and  ligature  as  soon  as  it  had 
erupted  sufficiently,  and  thus  brought  in  normal  alignment. 


Fig.   19i 


Retaining  appliance  which  was  modified  for  use  in  Case  G. 


Maintenance  was  effectually  provided  by  the  appliances 
shown  in  Fig.  194,  omitting  the  band  upon  the  central 
incisor.  The  right  central  was  maintained  in  its  corrected 
position  by  means  of  a  w4re  ligature  tied  around  the  lingual 
connecting  wire.  The  hooks  upon  the  upper  canine  and  lower 
molar  bands,  for  use  with  elastic  rubbers,  were  also  dis- 


236 


TREATMENT  OF  NEUTROCLUSION 


pensed  with.     The  facial  deformity  and  its  correction  are 
shown  in  Fig.  195. 

Fig.  195 


A 

1  ^ 

1 

1 

Facial  relations  before  and  after  treatment  of  Case  G. 


Case  H. —  Neutroclusion  complicated  by  supra-linguoversion 
of  the  incisors.  An  anemic  boy,  aged  thirteen  years  (Figs. 
196  and  197),  who  has  frequently  been  troubled  with  severe 
attacks  of  tonsilitis.     Examination  revealed  a  pronounced 


COMPLEX  NEUTROCLUSION 


237 


hypertrophy  of  the  tonsils,  for  which  treatment  by  a 
rhinologist  was  requested.  Their  removal  having  been 
executed,  the  malocclusion  was  corrected  by  simultaneous 
expansion  of  both  arches. 


Fig.  196 


Neutroclusion  complicated  by  supra-linguoversion  of  the  incisors,  before 
and  after  treatment,  Case  H. 


The  appliances  for  treatment  consisted  of  four  anchor 
bands  and  two  16-gauge  alignment  wires  applied  as  in  Fig. 
112  for  the  upper,  and  Fig.  167  for  the  lower.  The  right 
lower  first  and  second  bicuspids  were  provided  with  plain 
bands  and  spurs  for  their  rotation,  as  in  Fig.  168.  The 
lower  canines  were  similarly  banded.     The  upper  incisors 


238 


TREATMENT  OF  NEUTROCLUSION 


were  carried  labially  by  means  of  silk  ligatures  without 
banding. 

In  the  lower  arch  the  four  incisors  were  first  attached. 
After  considerable  labial  movement  the  cuspids  were 
included,  with  rotary  action.  Subsequently  the  bicuspids 
were  ligated  to  the  wire.  The  anchor  bands  had  been  so 
adjusted  that  their  clamping  bolts  embraced  the  second 

Fig.  197 


^^^^^^H 

mm 

MI^I^I^^H 

«■ 

B^r  ^' '^ 

^  '^'  ^1 

^^' 

« 

H^v  * 

s  "»  ■ 

^^^^r^  \ 

'    m 

m  ' ' 

\  \ 

^m 

V  'i  ■;* 

■ 

t    «.      M 

K  &.    * 

mm 

%  *''"^^B 

Hki^^'^^^ 

"'  "i-^l 

^^Km^jL^m^^s 

|ttg|||||fl 

H||^^_g 

n^^^l 

^^^^^r^fm^^^ 

iHiniiiijiH 

PppHB 

^^^ 

"^H 

r     ^"C 

vl 

'^^^P. 

nH 

J 

Bk            ^^    *^%i 

fm 

^^L                                             'O;')^, 

^■H 

^^             (^-  ^L. 

''^M 

^m 

yii 

-Jm 

Occlusal  views  of  models  in  Fig.  196. 


molars,  thus  enlisting  their  additional  support.  But  it 
will  be  noted  that  the  left  lower  lateral  half  has  moved 
slightly  distal  to  normal,  notwithstanding  the  fact  that 
intermaxillary  anchorage  was  applied  as  soon  as  this  ten- 
dency asserted  itself.  Hence  its  continuance  was  provided 
for  in  the  retention  appliance. 

Maintenance   appliances  consisted  of  an  apparatus  for 


COMPLEX  NEUTROCLUSION 


239 


the  lower  as  illustrated  in  Fig.  140,  with  a  hook  attached 
to  the  buccal  surface  of  the  left  lower  molar  band  for  the 


Fig.  198 


Facial  relations  before  and  after  treatment  in  Case  H. 


intermaxillary  elastic,  and  the  union  of  the  two  bands  on  the 
right  lower  bicuspids.  These  bands  were  united  with  solder 
at  their  points  of  contact,   and  then  reset  with   cement. 


240 


TREATMENT  OF  NEUTROCLUSION 


In  the  upper  arch  an  appliance  like  Fig.  194  (upper  diagram) 
was  applied,  with  the  exception  that  the  spur  on  the  right 


Fig.  199 


Front  views  of  the  models  of  Case  H,  before  and  after  treatment. 


upper  cuspid  band  was  dispensed  with.  Similarly,  the 
incisor  band  shown  in  the  drawing  was  prepared  for  the 
right  central,  instead  of  the  left. 


COMPLEX  NEUTROCLUSION  241 

The  vast  improvement  in  his  facial  expression  and  general 
well-being  is  clearly  shown  in  the  photographs  in  Fig.  198. 
The  correction  of  the  occlusal  plane,  which  had  been  totally 
destroyed  in  the  anterior  region  of  the  arches  by  the  marked 
"overbite,"  is  shown  in  Fig.  199.  This  was  only  partly 
affected  by  the  manner  of  application  of  the  ligatures  to  the 
upper  incisors  (see  Fig.  172);  and  by  the  action  of  the  align- 
ment wire  on  the  lower  (see  Fig.  173).  The  most  effective 
aid  for  the  removal  of  such  deviations  is  shown  in  Fig.  200, 
which  promotes  an  elongation  of  the  posterior  teeth. 

Fig.  200 


m\w.v\\\\\\^\^i-o.vw'avav,m'j^Q; 


v= 


Intermaxillary  anchorage  modified  to  effect  elongation  of  the  molars. 

Case  I. —  Neutroclusion  complicated  hy  extreme  infraversion 
of  the  incisors,  cuspids,  and  first  bicuspids.  A  girl,  aged 
sixteen  years  (Figs.  201  and  202),  who  was  referred  by  a 
rhihologist  after  having  been  operated  on  for  adenoids. 
It  is  extremely  doubtful,  however,  whether  they  had  any 
causal  relation  to  the  malocclusion.  The  arches  are  too 
symmetrical  to  indicate  nasal  involvement.  Examination 
revealed  an  unusually  large  tongue,  and  the  patient  admitted 
being  addicted  to  the  habit  of  nursing  same. 

Aside  from  the  elongation  required  for  all  the  teeth 
involved,  the  arches  need  slight  alteration  in  form  by  widen- 
16 


242  TREATMENT  OF  NEUTROCLUSION 

ing  in  the  region  of  the  cuspids,  and  a  rotation  of  the  lower 
centrals,  which  are  in  torso  version.  The  infra  version  is, 
moreover,  too  extensive  to  warrant  an  attempt  at  correction 

Fig.  201 


Side  views  before  and  after  treatment  of  Case  I. 

by  using  only  the  spring  of  the  alignment  wire.  Such  an 
attempt  would  surely  result  in  displacement  of  the  molar 
teeth  (see  Fig.  170).  Hence  the  use  of  direct  intermaxillary 
anchorage  (Fig.   171)  was  resorted  to.     The  incisors  and 


COMPLEX  NEUTROCLUSION 


243 


canines  were  provided  with  bands  spurred  as  in  Fig.  203. 
These  afforded  secure  adjustment  for  the  ahgnment  wires, 
and  were  carefully  prepared  and  set  with  cement,  so  that 
they  were  all  on  the  same  plane.  The  intermaxillary  elastics 
were  worn  constantly  during  the  hours  of  sleep  and  during 
as  many  of  the  waking  hours  as  was  compatible  with  the 
patient's  necessary  comforts. 

Fig.  202 


^ 

<ii--'' 

!'  ft,  '    i^^B 

.^-^-iy- 

Occlusal  views  before  and  after  treatment  of  case  shown  in  Fig.  201 


During  the  first  stages  of  treatment  the  elastic  bands  were 
cut  from  one-eighth-inch  rubber  tubing,  and  were  so  thin 
as  to  exert  on];\'  gentle  pressure.  Gradually  their  thickness 
was  increased,  and  ultimately  two  were  applied  to  each  side. 
These  extra  precautions  were  exercised  to  prevent  death 
of  the  pulps.    The  treatment  occupied  a  period  of  six  months. 


244  TREATMENT  OF  NEUTROCLUSION 

Maintenance  has  now  been  effectually  provided  by  appli- 
ances of  a  design  as  shown  in  Fig.  140.  Small  hooks,  con- 
structed of  20-gauge  wire,  were  soldered  to  the  labiogingival 
borders  of  the  canine  bands,  to  which  light  elastics  were 
applied  at  night,  and  subsequently  on  alternate  nights.    In 

Fig.  203 


Shows  band  used  for  anchorage  of  the  aUgnment  wires  in  treating  Case  I. 

addition,  the  central  incisors  were  provided  with  plain  bands 
with  spurs  on  their  lingual  surfaces,  so  placed  as  to  overlap 
the  lingual  connecting  wire.  These  bands  were  also  united 
with  solder  before  cementing  into  position,  thus  adding 
strength  to  the  upper,  and  retaining  the  lower  corrected 
torso  versions. 


CHAPTER    XVI 

TREATMENT  OF  DISTOCLUSION 

BILATERAL  DISTOCLUSION 

The  distinguishing  characteristic  of  this  type  of  deformity 
is  a  bilateral  distal  relation  of  the  lower  arch  when  the  teeth 
are  brought  into  occlusion.  This  may  be  due  (a)  to  disto- 
version  of  the  lower  teeth,  (b)  to  arrest  of  development  of 
the  mandible,  or  (c)  to  a  posterior  development  of  the  glenoid 
fossse,  resulting  in  a  posterior  position  of  the  lower  jaw.^  The 
various  minor  peculiarities  which  usually  complicate  cases 
belonging  to  this  class  are  practically  identical  with  those 
of  complex  neutroclusion. 

Bilateral  Distoclusion.  Complicated  by  Extreme  Labioversion  of 
the  Upper  Incisors 

Case  J. — A  delicate  and  timid  boy,  aged  eight  years  (Figs. 
204  and  205) ,  who  had  adenoids  removed  during  his  fifth  year 
by  a  rhinologist.  He  has,  from  infancy,  been  troubled  with 
rhinitis  and  mouth  breathing  which  the  above-mentioned 
operation  and  continued  nasal  treatment  failed  to  cure.  He 
had  recently  been  placed  under  the  care  of  another  rhinolo- 
gist, who  immediately  recognized  the  extreme  dentofacial 
deformity  and  the  utter  futility  of  nasal  treatment  unassisted 
by  orthodontic  treatment.  The  facial  deformity  and  arrest 
of  development  of  the  mandible  at  this  time  are  clearly 

'  Federspiel,  Proc.  Amer.  Soc.  Orthodontists,  1911. 


246  TREATMENT  OF  DISTOCLUSION 

shown  in  Fig.  84.  The  narrowing  of  the  upper  arch  (which  is 
symptomatic  of  such  an  abnormal  nasal  condition)  is  shown 
in  the  upper  occlusal  view  of  Fig.  205  (left  upper  corner). 

Fia.  204 


Side  views  before  and  after  treatment  of  Case  J. 

The  plan  of  treatment  adopted  in  this  case  was  after  the 
method  suggested  by  Angle,  for  which  an  appliance  com- 
posed of  the  following  elements  was  used:  Four  molar 
anchor  bands  with  buccal  tubes  and  lingual  extension  wires, 
as  previously  described,  were  anchored  to  the  first  permanent 


BILATERAL  DISTOCLUSION 


247 


molars;  two  16-gauge  alignment  wires  with  tube  hooks  for 
the  upper;  four  plain  bands  with  spurs  on  the  distogingival 
borders  of  their  lingual  surfaces  for  the  upper  incisors.  The 
lower  incisors  were  tied  to  the  alignment  wire  with  silk 
ligatures.  The  lingual  extension  wires  were  similarly  fastened 
to  the  alignment  wire  for  the  expansion  of  the  lower  arch. 


Fig.  205 


Occlusal  views  of  Case  J. 


This  apparatus  furnished  the  source  of  anchorage  for  inter- 
maxillary elastics  attached  to  the  tube  hooks  on  the  upper 
wire  (see  Fig.  122). 

In  the  early  stages  of  treatment  only  the  lingual  wires 
were  tied  to  the  upper  alignment  wire,  to  promote  buccal 
movement  of  the  upper  temporary  teeth.  The  nuts  mesial 
to  the  buccal  tubes  were  so  adjusted  that  the  alignment  wire 


248 


TREATMENT  OF  DISTOCLUSION 


on  the  upper  arch  failed  in  contact  with  the  labial  surfaces 
of  the  incisors.  Hence  the  pressure  of  the  intermaxillary 
elastics  was  entirely  exerted  upon  the  upper  first  permanent 
molars,  resulting  in  their  full  distal  movement.  This  being 
accomplished,  the  nuts  were  released  and  the  alignment 
wire  allowed  to  rest  upon  the  incisors,  which  resulted  in  a 
reduction    of   their   labioversion.      Finally,    ligatures   were 

Fig.  206 


Facial  relations  of  Case  J  after  four  months  of  treatment.    (Compare  with  Fig.  84.) 


passed  from  the  lingual  spurs  on  their  bands  to  the  align- 
ment wire  to  effect  their  rotation.  Such  ligation  in  the 
earlier  stages  must  always  be  dispensed  with,  to  avoid 
undue  elongation. 

The  treatment  up  to  the  time  of  maintenance  occupied 
a  period  of  four  months.  The  occlusion  of  the  teeth  at  this 
time  is  shown  in  the  illustrations  already  referred  to,  and  the 
vast  improvement  in  facial  balance  is  set  forth  in  Fig.  206. 


BILATERAL  DISTOCLUSION  249 

It  may  be  of  interest  to  note  that  mouth  breathing  ceased 
entirely  during  the  second  month  of  orthodontic  treatment. 

Maintenance  is  being  successfully  accomplished  by  an 
appliance  similar  to  that  shown  in  Fig,  179,  though  the 
following  minor  alterations  were  necessitated  by  the  disto- 
clusion.  The  lower  molar  bands  were  provided  with  small 
hooks  constructed  of  20-gauge  iridioplatinum  wire  attached 
to  their  mesiobuccal  angles,  close  to  the  gingival  margin. 
The  two  bands  upon  the  upper  lateral  incisors  were  connected 
with  a  labial  wire  of  the  same  gauge,  which  was  bent  into 
hook  form  at  each  end,  immediately  distal  to  the  canine 
embrasure.  During  the  first  month  of  retention,  delicate 
elastics  were  worn  continuously.  Subsequently  their  use 
was  limited  to  the,  hours  of  sleep,  and  in  the  last  half  of 
the  first  year  to  the  sleeping  hours  on  alternate  nights 
only. 

The  entire  appliance  was  now  removed  and  the  teeth 
thoroughly  cleansed,  after  which  it  was  reset.  The  latter 
precaution  was  for  a  twofold  purpose;  partly  to  maintain 
the  form  of  the  arches,  but  more  especially  to  exert  a  con- 
trolling influence  on  the  erupting  bicuspids.  In  this  stage 
of  retention  the  lingual  wire  is  of  inestimable  value.  The 
growth  in  the  mandible  during  the  last  year  has  been  very 
marked. 

Case  K. — A  strong  boy,  aged  twelve  years  (Figs.  207  and 
208),  whose  history  does  not  relate  nasal  treatment.  Nor 
did  an  examination  by  a  rhinologist  reveal  any  pathological 
nasal  condition,  though  he  is  a  confirmed  mouth  breather. 
It  will  be  noted,  too,  that  the  occlusal  views  of  the  pre- 
treatment  models  (Fig.  208)  exhibit  rather  symmetrical 
arches  with  very  little  arrest  of  development.  The  facial 
deformity  is  not  nearly  as  severe  as  in  Case  J.    There  can  be 


250 


TREATMENT  OF  DlSTOCLUSlON 


no  doubt  that  this  deformity  was  easily  recognizable  during 
his  sixth  year,  possibly  earlier,  though  on  this  point  his 
parents  are  not  certain.    Such  malocclusions  are  frequently 


Fig.  207 


Side  views  before  and  after  treatment  of  Case  K. 


attributed  to  nasal  obstruction,  and  explained  on  the 
hypothesis  that  adenoid  vegetations  were  undoubtedly  a 
contributing  cause  during  childhood,  and  that  their  resorp- 
tion (which  is  known  to  occasionally  take  place)  has  removed 


BILATERAL  DlSTOCLUSION 


251 


every  trace  of  them.     But  that  is  purely  an  hypothesis  and 
difficult  of  conclusive  demonstration. 

Furthermore,  this  boy  provides  the  following  interesting 
family  history:  His  father  is  dark  haired,  of  English  descent, 
presents  an  extreme  bilateral  distoclusion  of  a  type  under 
consideration,  and  a  very  decided  dolichocephalic  head 
form.    In  short,  his  is  a  typical  adenoid  face.    His  mother. 

Fig.  208 


Occlusal  views  of  Case  K. 


on  the  other  hand  (whom  he  strongly  resembles  in  com- 
plexion, hair  and  eye  color,  as  well  as  in  tooth  form),  is  of 
Celtic  extraction,  of  the  reddish  blonde  type,  with  freckled 
skin,  with  prominent  malar  bones,  brachycephalic  head  form, 
and  prognathous  denture  (though  normal  in  occlusion). 
Hence  the  temptation  to  blame  heredity  for  the  deformity, 
to  speak  of  it  as  an  inherited  disharmonism.    But  this  would 


252  TREATMENT  OF  DISTOCLUSION 

again  be  purely  an  hypothesis  and  equally  difhcult  of  veri- 
fication. 

Treatment  was  similar  to  that  described  for  Case  J, 
though  the  lingual  extension  wires  were  dispensed  with  in 
the  upper  arch.  The  molar  anchor  bands  were  adjusted 
with  their  clamping  bolts  pointing  distally.  After  the 
normal  mesiodistal  relations  between  the  molars  had  been 
established  by  means  of  the  intermaxillary  elastics,  the 
upper  molar  bands  were  removed  and  bands  placed  upon 
the  second  bicuspids.  The  first  bicuspids  were  attached 
to  these  with  wire  ligatures.  After  their  distal  movement, 
the  nuts  were  released  and  pressure  brought  to  bear  upon 
the  upper  incisors.  In  the  meantime  the  lower  arch  was 
gradually  enlarged  for  the  accommodation  of  the  left 
canine. 

An  interesting  feature  of  the  case  was  a  porcelain  crown 
upon  the  left  upper  central  incisor,  but  which  did  not  become 
the  seat  of  any  discomfort.  There  being  no  torsoversion 
present  in  any  of  the  upper  incisors,  plain  bands  were 
contraindicated . 

The  retention  appliance  was  identical  in  design  to  that 
described  for.  Case  J.  The  bands  shown  in  the  after  treat- 
ment models  of  the  illustrations  were  substituted  for  same 
at  the  close  of  the  period  of  retention. 

Case  L. — A  youth  aged  nineteen  years  (Figs.  209  and  210), 
showing  complete  distoclusion  as  a  result  of  postponement  of 
treatment.  Note  the  extreme  narrow  upper  arch,  and  the 
pronounced  labio version  of  the  upper  incisors.  This  case 
is  a  fine  exhibition  of  the  axiom  set  forth  in  the  chapter  on 
Prognosis,  that  nature  and  time  rarely  exert  a  corrective 
influence  on  a  malocclusion. 

The  improvements  in  the  occlusion  of  the  teeth  shown  in 


BILATERAL  DISTOCLUSION  253 

the  illustrations  were  accomplished  in  the  short  period  of 
four  months.  The  case  is  one  of  the  first  the  author  ever 
attempted  to  treat,  and  as  he  now  reflects  over  his  seeming 
achievement,  he  is  quite  convinced  that  a  radical  change 
in  the  temporomandibular  articulation,  viz.,  the  mounting 

Fig.  209 


Side  views  before  and  after  treatment  of  Case  L. 

of  the  condyles  on  the  eminentia  articularis,  was  largely 
responsible  for  the  results. 

The  treatment  was  identical  to  the  plan  already  described, 
though  retention  was  provided  with  vulcanite  plates  with 
labial  wires.     The  effect  upon  the  facial  lines  is  shown  in 


254 


TREATMENT  OF  DISTOCLUSION 
Fig.  210 


Occlusal  views  of  Case  L. 
Fig.  211 


r' 


Profile  of  Case  L,  before  and  after  treatment. 


BILATERAL  DISTOCLUSION 


255 


Fig.  211.  The  corrected  condition  was  readily  maintained 
for  two  years,  during  which  time  the  patient  was  under  the 
author's  care.  Since  then  he  has  lost  all  trace  of  him,  and 
he  regrets  that  the  ultimate  results  are  not  now  available. 


Fio.  212 


Side  views  of  Case  M. 


Such  extreme  deformities  form  interesting  studies  from 
various  points  of  view.  First,  they  recall  the  inclined  plane 
of  Catalan  and  Kingsley  for  "jumping  the  bite;"  second, 
they  emphasize  the  many  recent  criticisms  directed  against 


256  TREATMENT  OF  DISTOCLUSION 

that  plan  of  treatment;  third,  they  forcibly  impress  one  with 
the  necessity  for  early  treatment,  since  they  offer  convincing 
proof  that  neglect  frequently  results  in  jaw  deformity,  after 
which  the  accompanying  malocclusions  are  but  symptoms. 
(See  Chapter  XVIII.) 

Bilateral  Distoclusion  Complicated  by  Linguoversion  of  the 
Upper  Incisors 

Case  M. — A  girl,  aged  ten  years  (Figs.  212  and  213),  with 
negative  history.  The  facial  deformity  was  marked,  and 
of  a  type  as  illustrated  in  Fig.  83.    The  prognosis  of  cases 

Fig.  213 


Occlusal  views  of  Case  M.     (The  lower  models  should  be  transposed.) 

belonging  to  this  group  has  previously  been  emphasized, 
the  tendency  being  toward  an  arrest  of  development  in  the 
mandible  (see  Fig.  89).  Postponement  of  treatment  would 
unquestionably  result  in  an  aggravation  of  the  deformity. 


BILATERAL  DISTOCLUSION 


257 


Treatment  was  instituted  by  means  of  anchor  bands, 
alignment  wires,  plain  bands  for  the  upper  incisors,  and 
intermaxillary  elastics.  The  details  of  application  are  in 
many  respects  similar  to  those  described  for  the  former 
group,  though  there  is  need  for  less  widening  of  the  arches. 
Furthermore,  the  upper  centrals  require  a  labial  movement, 
which  can  easily  be  accomplished  by  reciprocal  anchorage 
in  combination  with  the  lingual  movement  of  the  adjoining 
laterals  (see  Fig.  147). 


Fia.  214 


Retaining  device  for  the  upper  arch  of  Case  M,  providing  for  a  continuance 
of  the  intermaxillary  elastics.    (After  Rogers.) 

As  pointed  out  by  Angle,  the  loss  of  occlusion  of  the 
anterior  teeth  permits  their  elevation,  so  that  the  treatment 
should  aim  at  a  reduction  of  their  supra  version.  But  in 
view  of  the  fact  that  such  action  is  extremely  diflficult  to 
obtain,  and  a  growth  of  the  mandible  especially  desirable, 
the  plan  illustrated  in  Fig.  200  (resulting  in  an  elongation 
of  the  molars)  has  been  widely  accepted. 

Such  continued  action  of  the  intermaxillary  elastics  is 
now  provided  for  in  the  retaining  appliance  (Fig.  214).  The 
17 


258 


TREATMENT  OF  DISTOCLUSION 


bands  upon  the  centrals  are  united  and  attached  to  the 
lingual  wire,  which  extends  to  the  molar  bands,  thus  pro- 
viding for  maintenance  of  arch  form.  In  addition,  an 
inclined  plane  of  metal  is  provided,  and  so  adjusted  that  the 


Fig.  215 


Side  views,  before  and  after  treatment,  of  Case  N. 


"bite"  will  remain  open  to  the  desired  height  (section  a-a). 
On  the  labial  surfaces  of  the  incisor  bands  extended  hooks 
are  provided  for  the  fastening  of  the  elastics,  which  are  also 
attached  to  hooks  on  the  upper  and  lower  molar  bands.    In 


BILATERAL  DISTOCLUSION 


259 


the  lower  arch  the  appliance  usually  follows  the  design 
illustrated  in  Figs.  140  and  179,  depending  on  whether  the 
canines  have,  or  have  not,  erupted. 

Case  N. — A  girl,  aged  thirteen  years,  the  daughter  of  a 
physician,  with  negative  history  (Figs.  215  and  216).  The 
etiology  in  such  cases  is  still  obscure ;  they  are  in  all  probabil- 
ity due  to  intrinsic  factors  which  we  have  failed  to  recog- 

FiG.  216 


Occlusal  views,  before  and  after  treatment,  of  Case  N. 


nize.  The  normal  nasal  and  lip  function  accompanying 
this  type  naturally  implies  facial  deformities  less  severe 
than  in  the  group  complicated  by  labioversion  of  the  upper 
incisors  and  nasal  obstruction.  A  well-developed  mental 
eminence  in  this  case  especially  precluded  the  possibility 
of  severe  facial  deformity  (Fig.  217). 

The  details  of  treatment  were  practically  the  same  ag 


260 


TREATMENT  OF  DISTOCLUSION 


for  the  former  case,  except  that  the  laterals  were  carried 
labially  with  the  centrals,  and  the  rubber  wedge  for  reciprocal 
action  applied  to  the  canines.     The  bicuspids  were  carried 


Fia.  217 


Facial  relations,  before  and  after  treatment,  of  Case  N. 


slightly  buccally,  and  distal  movement  of  the  upper  and 
mesial  movement  of  the  lower  molars  affected  by  inter- 
maxillary elastics. 


BILATERAL  DISTOCLUSION  261 

For  maintenance  after  tooth  movement,  an  appliance  as 
shown  in  Fig.  140  was  apphed  to  the  lower  arch,  with  the 
addition  of  hooks  to  the  buccal  surfaces  of  the  molar  bands. 
In  the  upper  arch  a  plain  band  upon  each  lateral  was  con- 
nected with  a  wire  on  the  labial  extending  distally  beyond 

Fio,  218 


Side  views,  before  and  after  treatment,  of  Case  O. 

the  labial  eminences  of  the  canines  and  ending  in  a  hook, 
for  the  reception  of  intermaxillary  elastics  anchored  to  the 
lower  molars.  These  were  worn  during  the  sleeping  hours  for 
a  period  of  six  months,  then  on  alternate  nights  only  for  the 
remainder  of  a  year,  after  which  all  appliances  were  removed. 


262  TREATMENT  OF  DISTOCLUSION 

Case  O. — A  boy,  aged  fourteen  years  (Figs.  218  and  219), 
who  presents  an  extreme  deformity.  An  unusual  feature  of 
the  case  is  the  arrest  of  development  of  the  arches,  with 
linguo version  of  the  upper  molars  and  bicuspids.  This 
rarely  is  so  severe  in  cases  with  linguo  version  of  the  incisors. 


Fig. 

219 

■■ 

w 

IB^ 

^^^H 

^^^^^PBr^^ 

1 

r 

^^1 

^^BK^^ 

^|HF; 

;'^ 

'%'^^H 

^&>        ^^^H 

m 

^^ 

■ 

^MH 

1 

y 

^ 

Mi 

^/^y^^^H 

Occlusal  views,  before  and  after  treatment,  of  Case  O. 

A  stud}^  of  the  case  readily  reveals  the  requirements  of 
treatment;  both  arches  require  considerable  expansion;  the 
lower  arch  a  mesial  movement;  the  upper  a  distal  move- 
ment for  molars,  bicuspids,  and  canines,  and  labial  move- 
ment for  the  lateral  incisors.  The  upper  central  incisors 
occupy  an  approximately  normal  position,  labiolingually, 
though  all  four  incisors  demand  a  correction  of  their  torso- 


BILATERAL  DISTOCLUSION  263 

version.  The  various  details  were  carried  out  as  follows: 
Molar  anchor  bands  were  fitted  to  the  lower  first  molars 
and  bands  adapted  to  the  lower  canines,  with  spurs  on  the 
distogingival  borders  of  their  lingual  surfaces.  The  clamp- 
ing bolts  on  the  anchor  bands  were  allowed  to  point  distally, 
thus  embracing  the  second  molars  (Fig.  167).  After  all  the 
lower  teeth  were  tied  to  the  lower  alignment  wire,  and 
expansion  of  the  lower  arch  thus  prepared  for,  the  upper 
molar  anchor  bands  with  buccal  tubes  were  similarly  placed. 
An  alignment  wire  with  tube  hooks  opposite  the  upper 
canines  was  now  inserted  as  high,  gingivally,  as  the  canines 
would  permit,  though  not  encircling  them,  and  the  nuts 
so  adjusted  that  it  failed  to  rest  upon  the  incisors.  The 
application  of  intermaxillary  elastics  from  lower  molar 
tubes  to  upper  hooks  (first  one  for  each  side,  then  two), 
caused  a  distal  movement  of  the  upper  molars.  The  expand- 
ing action  of  the  alignment  wire  produced  their  buccal 
movement,  the  clamping  bolts  carrying  the  second  molars. 
This  occupied  a  period  of  two  months.  The  upper  molar 
bands  were  now  removed,  and  similar  bands  placed  upon 
the  upper  second  bicuspids,  with  their  clamping  bolts 
pointing  mesially  to  embrace  the  first  bicuspids.  The  latter 
were  tied  to  the  anchor  bands  by  means  of  wire  ligatures, 
gauge  26.  The  upper  alignment  wire  was  reinserted  and  its 
adjustment  so  controlled  that  it  encircled  the  canines  and 
rested  firmly  on  their  labial  eminences.  The  incisors  were 
now  attached  with  silk  ligatures  as  in  Fig.  165,  and  the 
action  of  the  intermaxillary  elastics  resumed  until  the  rela- 
tions shown  in  the  after-treatment  models  were  established. 
The  lower  arch  was  provided  with  an  appliance  as  in 
Fig.  140,  though  the  clamping  bolts  on  the  molar  bands  were 
retained.    Hooks  were  also  soldered  to  the  buccal  surfaces 


264  TREATMENT  OF  DISTOCLVSION 

after  the  buccal  tubes  were  detached,  as  previously  described. 
In  the  upper  arch  an  appliance  similar  to  that  in  Fig.  179 
(upper  diagram)  was  adjusted.  The  anchor  bands  origin- 
ally used  on  the  upper  first  molars  were  employed,  and  their 
clamping  bolts  pointing  in  a  distal  direction  allowed  to 
remain.  The  two  plain  bands  upon  the  laterals  were  con- 
nected wdth  a  labial  wire  bent  into  hook  form  at  each  end, 
and  of  sufficient  length  to  embrace  the  canines.  The  main- 
tenance of  the  corrected  arch  form  was  thus  provided  for, 
as  well  as  the  arch  relation  by  continued  use  of  the  inter- 
maxillary elastics. 

Fig.  220 


Modification  of  intermaxillary  force  for  correction  of  labio-infraversion  compli- 
cating distoclusion. 


Bilateral  Distoclusion,  Complicated  by  Labio-infraversion  of 
the  Upper  Incisors 

This  type  of  malocclusion  is  exceedingly  rare.  Fig.  41,  B, 
shows  the  right  view  of  a  case  from  the  author's  practice, 
being  a  girl,  aged  nine  years.  The  central  incisors  began 
erupting  during  the  seventh  year,  but  the  pernicious  habit 
of  tongue-sucking  prevented  them  from  assuming  a  normal 
length.  The  patient  was  also  affiicted  with  hypertrophy 
of  the  tonsils  and  inferior  turbinates.     In  the  treatment, 


UNILATERAL  DISTOCLUSION  265 

the  ligation  of  the  incisors  is  not  only  immediately  desir- 
able (which  was  contraindicated  in  the  cases  previously 
described),  but  should  even  be  intensified  by  the  appli- 
cation of  the  elastics  as  in  Fig.  220. 

Fig.  221 


Side  views,  before  and  after  treatment,  of  Case  P. 

UNILATERAL  DISTOCLUSION 

As   its   name   implies,   cases    belonging    to    this    group 
present  a  distal  relation  of  the  lower  on  one  side  only, 


266 


TREATMENT  OF  DISTOCLUSION 


the   other  side   being   as   in   neutroclusion.     The   compli- 
cations are  similar  to  those  affecting  the  bilateral  types. 


Unilateral  Distoclusion,  Complicated  by  Labioversion  of  the 
Upper  Incisors 

Case  P. — A  boy,  aged  twelve  years  (Figs.  221  and  222), 
who  had  an  operation  for  adenoids  performed  during  his 
tenth  year,  and  who  is  still  under  treatment  for  chronic 
rhinitis.     The  distal  closure  of  the  lower  is  readily  seen  in 

Fig.  222 


Occlusal  views,  before  and  after  treatment,  of  Case  P. 

the  right  view  of  the  pre-treatment  models,  as  are  also 
the  other  minor  complications  with  which  the  reader  has 
become  familiar  through  a  consideration  of  the  bilateral 
type.  These  are  briefly  enumerated  by  Angle  as  follows: 
Narrowing   of   the   upper   arch,   elongation   of   the   upper 


UNILATERAL  DISTOCLUSION 


267 


incisors,  abnormal  nasal  and  lip  function,  and  distortion 
of  the  facial  lines,     (Compare  with  Figs.  204  and  205). 


Fia.  223 


Facial  relations,  before  and  after  treatment,  of  Case  P. 


The  first  requirement  of  the  treatment  which  naturally 
suggests  itself  is  the  mesiodistal  shifting  of  the  right  lower 
and  upper  first  molars,  by  means  of  reciprocal  intermaxillary 


268 


TREATMENT  OF  DlSTOCLUSlON 


anchorage.  Following  this  should  come  the  widening  of 
the  arches,  especially  in  the  bicuspid  region,  as  well  as 
a  correction  of  their  mesiodistal  relation  on  the  affected 


Fig.  224 


^^HHHHBnRv-vrTKc^n..^... — _;.;■.■... 

.,je*»^ 

"•'''"^  wBKk  iffiiiiliiicttilllifci 

^'^'''a'/-'*^ 

J 

H^'"'* 

'\ 

3B|^R>  '\ 

Mi^.y'V 

k' 

■■H 

* 

1 

|;  ^mfm 

^'■^ 

^m    ' 

J 

^K   ... 

■  --t.--  -■-»HT-Ja^ 

■■H 

Side  views,  before  and  after  treatment,  of  Case  Q. 


side.  The  nuts  on  the  upper  arch  are  now  released  and 
pressure  allowed  to  fall  upon  the  protruding  incisors,  for 
the  reduction  of  their  labioversion. 

Maintenance  was  in  every  respect  similar  to  that  described 
for  Case  J,  with  the  exception  that  the  continuance  of 


UNILATERAL  DISTOCLUSION 


269 


intermaxillary  force  during  the  sleeping  hours  was  provided 
only  for  the  right,  or  previously  abnormal  side.  Fig.  223 
shows  the  marked  improvement  in  the  facial  relation. 

Unilateral  Distoclusion,  Complicated  by  Linguo-supraversion  of 
the  Upper  Incisors 

Case  Q. — A  young  miss,  aged  sixteen  years  (Figs.  224  and 
225),  with  negative  history,  presenting  normal  nasal  and 
lip  function,  and  hut  slight  distortion   of  the  facial  lines. 


Fig.  22") 

?^ 

^ 

li[|^^H| 

■ 

i 

I^V 

life-.' 

" 

^K  !L  "^ 

^ . ."^'^^^^^^^1 

■1 

A 

^^   '^^ 

'.d0^l 

m 

^^ 

HHk  /^ 

s^^fll 

Occlusal  views,  before  and  after  treatment,  of  Case  Q. 


Treatment  consisted  in  first  mo\ing  the  left  upper  molars 
and  bicuspids  distally  (as  previously  described),  after  which 
the  upper  incisors  were  moved  labially,  and  by  a  continuation 
of  the  intermaxillary  elastics  a  mesial  tipping  of  the  lower 


270  TREATMENT  OF  DISTOCLUSION 


Fig.  226 


Modified  application  of  intermaxillary  anchorage  for  median  line  deviations. 
(After  Reoch.) 


Fig.  227 


Modification  for  simpler  devi9,tioq3.    (After  Angle.) 


UNILATERAL  DISTOCLUSION  271 

left  side  was  effected.  The  left  upper  canine,  having  pre- 
viously been  provided  with  a  plain  band  with  a  spur  upon 
its  lingual  surface,  at  its  mesiogingival  angle,  was  likewise 
moved  into  normal  position  in  the  arch. 

The  corrected  torsoversion  in  the  upper  central  incisors 
was  maintained  with  two  plain  bands  united  by  solder  at 
their  mesial  contact  points.  The  band  upon  the  left  upper 
canine  was  replaced  after  a  hook  had  been  attached  to  the 
distogingival  angle  of  its  labial  surface.  The  left  lower 
molar  band  was  provided  with  a  similar  hook  on  its  buccal 
surface  after  the  buccal  tube  was  detached,  and  an  elastic 
was  then  applied  to  them  nightly.  This  was  continued  for 
some  eight  months,  after  which  they  were  removed,  with 
the  occlusion  improved  to  a  normal  relation. 

In  extreme  cases  of  unilateral  distoclusion  pronounced 
deviations  of  the  median  line  frequently  exist.  To  over- 
come such  marked  deviations,  particularly  in  older  patients, 
the  application  of  an  elastic  on  the  normal  side,  as  in  Fig. 
226,  may  at  times  be  indicated.  In  less  severe  cases,  but 
which  do  not  yield  after  continued  application  of  the  elastic 
on  the  normal  side,  and  in  cases  of  neutroclusion  and 
unilateral  mesioclusion  which  may  present  such  deviations, 
the  application  of  an  elastic  as  in  Fig.  227  is  indicated. 


CHAPTER    XVII 

TREATMENT  OF  MESIOCLUSION 

BILATERAL  MESIOCLUSION 

It  will  be  recalled  that  the  cases  comprising  this  group 
are  characterized  by  a  bilateral  mesial  relation  of  the  lower 
arch.  This  may  be  due  to  (a)  mesio version  of  the  lower 
teeth,  (h)  to  a  forward  position  of  the  mandible  and  its 
articular  fossae,  or  (c)  to  an  overdevelopment  of  the  bone, 
either  in  its  body  or  ascending  rami,  or  both.  And  though 
very  little  is  definitely  known  regarding  their  etiology  beyond 
the  factor  proposed  by  Case  (see  page  71),  all  observers 
agree  that  deformities  of  this  type  begin  at  an  early  age. 
Not  infrequently  arrest  of  development  of  the  maxilla,  as 
well  as  various  versions  of  a  number  of  the  teeth,  are  found 
as  complications.  Extreme  conditions  in  patients  of  ad- 
vanced years  are  more  properly  classified  as  presenting 
mandibular  deformities,  the  alleviation  of  which  lies  beyond 
the  scope  of  orthodontics  (see  Chapter  XVIII). 

The  accompanying  facial  deformities  are  often  pro- 
nounced, and  naturally  the  reverse  of  those  aggravating 
distoclusions.  Some  of  the  milder  forms  resemble  those  of 
neutroclusions  complicated  by  linguoversion  of  the  upper 
incisors  (compare  Figs.  182  and  236). 

Case  R. — A  girl,  aged  ten  years  (Figs.  228  and  229), 
afflicted  with  hypertrophy  of  the  tonsils,  gave  a  history  of 


BILATERAL  MESIOCLVSION 


273 


chronic  "sore  throat."  She  was  referred  to  a  rhinologist 
for  removal  of  the  enlarged  tonsils  and  such  treatment  of 
the  nose  and  throat  as  to  him  seemed  necessary.  The 
improvement  of  the  voice  and  breathing  which  followed 


Fig.  228 


Side  views  of  Case  R. 


was  marked.  Attention  is  also  directed  to  the  premature 
loss  of  the  lower  first  permanent  molars,  which  occurred 
during  her  sixth  year.  These  were  affected  by  extensive 
caries  and  consequent  pulp  exposure,  but  their  extraction 
was  a  serious  blunder,  and  not  only  failed  to  correct  the 
18 


274 


TREATMENT  OF  MESIOCLUSION 


deformity,  but  undoubtedly  aggravated  it  by  compelling 
mastication  with  the  anterior  teeth. 


Fig. 

229 

il 

1 

f^ 

81 

^^^Bf^tf^^ 

^«»l 

^r'^-wM 

1^^^^  ^1 

W^ 

1 

^^j 

1 

^^3^^^^ 

■4N 

^^^^.    ^^Wkit^'fitfi 

jg^i 

^ 

^ 

Occlusal  views  of  Case  R. 
Fig.  230 


^w^^yvvvW.'vV^Wv'vvwvv^^^?: 


^^^^:::::rr£^^^s 


AV^SVV'.'AVV^^'.VV-vVVWA^.^.waR' 


s 


o 


Manner  of  applying  intermaxillary  anchorage  for  mesioclusions. 


The  best  plan  for  the  treatment  of  these  cases  is  illus- 
trated in  Fig.  230,  being  a  reversal  of  the  intermaxillary 
anchorage  employed  in  distoclusions.  In  the  case  under 
discussion  the  upper  arch  was  provided  with  molar  anchor 


BILATERAL  MESIOCLUSION 


275 


bands  and  alignment  wire  after  the  manner  already  described. 
In  the  lower  a  decided  modijQcation  was  necessitated  by  the 
absence  of  the  permanent  first  molars.  Hence  the  canines 
were  provided  with  plain  bands  with  lingual  seam,  which 
were  then  united  by  a  labial  wire  soldered  to  their  gingival 
margins  and  terminating  in  a  well-formed  hook  at  each  end. 
The  latter  offered  anchorage  for  the  intermaxillary  elastics 


Fig.  231 


'^.^M 


Facial  relations  of  Case  R,  before  and  after  treatment. 


stretched  from  the  buccal  tubes  of  the  upper  molar  bands. 
The  author's  first  aim  was  to  induce  development  of  the 
upper  arch  and  to  restore  occlusion  of  the  anterior  teeth — 
to  bring  them  under  the  control  of  normal  influences.  Semi- 
weekly  visits  extending  over  a  month's  time  readily  accom- 
plished this,  with  a  change  in  the  profile  as  shown  in  Fig.  231. 
This  result  was  so  gratifying  that  the  author  felt  confident 
the  complete  control  of  the  deformity  was  now  assured. 


276  TREATMENT  OF  MESIOCLUSION 

Hence  the  upper  appliance  was  removed  and  a  retainer 
after  the  design  shown  in  Fig.  179  (upper  diagram)  sub- 
stituted. The  molar  bands  were  provided  with  buccal  hooks 
pointing  in  a  distal  direction,  thus  offering  attachment  for 
continued  use  of  the  elastics. 

Fig.  232 


Side  views  of  Case  S,  showing  the  progress  attained  during  three  and  one-half 
months. 

The  case  was  now  dismissed,  with  the  request  for  monthly 
visits.     At  the  close  of  the  first  year  the  post-treatment 


BILATERAL  MESIOCLUSION  277 

models  shown  in  the  half-tones  were  constructed,  and  further 
treatment  is  now  in  progress.  The  eruption  of  the  second 
molars  has  taken  place,  as  will  be  noted,  and  treatment 
of  the  remaining  versions  rendered  less  difficult. 

Fig.  233 


Occlusal  views  of  Case  S. 

Case  S. — A  girl,  aged  ten  years  (Figs.  232  and  233),  who 
had  hypertrophied  tonsils  removed  during  her  sixth  year. 
Orthodontic  treatment  was  postponed  for  one  year  with  the 
hope  that  the  left  upper  first  permanent  molar  would  make 
its  appearance.  But  not  until  the  tenth  year  did  this 
occur  (see  left  view  in  right  upper  corner  of  Fig.  232). 
Treatment  was  begun  February,  1911,  and  the  left  upper 
temporary  molar  used  for  anchorage,  this  tooth  being  still 
very  firm.  The  second  models  shown  in  the  illustrations 
were  made  in  May  (current  year)  just  prior  to  the  patient's 
departure  for  an  extended  trip. 


278  TREATMENT  OF  MESIOCLUSWN 

A  gratifying  change  in  the  progress  of  the  first  molar  is 
noticeable;  in  fact,  the  eruption  has  so  far  progressed  that 
the  temporary  retaining  device  was  anchored  to  it.  The 
eruption  of  the  upper  canines  and  first  premolars  was  pro- 

FiG.  234 


Side  views,  before  and  after  treatment,  of  Case  T. 

moted  by  the  extraction  of  their  temporary  predecessors 
immediately  after  the  first  models  were  made. 

The  maintenance  provided  is  similar  to  that  for  Case  R, 
though  the  upper  left  lateral  band  has  a  spur  of  20-gauge 


BILATERAL  MEStOCLVSION 


279 


wire  attached  to  its  labial  surface  which  extends  over  the 
erupting  canine.  The  labial  wire  on  the  lower  arch  is 
attached  to  bands  upon  the  lateral  incisors,  and  extends 
distally  to  embrace  the  erupting  canines.  The  use  of  inter- 
maxillary elastics  has  been  advised  during  the  entire  vaca- 
tion period  to  promote  growth,  as  well  as  maintenance,  of  the 
established  relations.    A  resumption  of  treatment  for  a  short 


Fig. 

235 

■^ 

1^9 

^^jj^^^^H 

^K^jW 

^P 

1^ 

^ir 

.^/yJl 

i^^ 

^Sl 

W^. 

4  ■™^;iw£'^ 

J^kgF^H 

1^ 

^^ 

^ 

Occlusal  views,  before  and  after  treatment,  of  Case  T. 


period  during  the  coming  autumn  will  effect  a  complete  cure. 
The  change  in  the  facial  relations  were  equally  as  gratifying 
as  in  Case  R. 

Case  T. — A  boy,  aged  eleven  years  (Figs.  234  and  235), 
who  was  referred  by  a  rhinologist  after  being  treated  for 
hypertrophy  of  the  tonsils.  Treatment  after  the  manner 
outlined  for  Cases  R  and  S  not  only  improved  the  facial 
expression  (Fig.  236),  but  his  general  health  as  well. 


m 


^R^A'TMEN'T  OF  MJESIOCLU'SWK 


Maintenance  was  provided  by  an  appliance  as  shown 
in  Fig.  194,  omitting  the  band  upon  the  upper  central 
incisor   and   reversing   the   attachment   of    the   hooks   for 


Fig.  236 


Facial  relations,  before  and  after  treatment,  of  Case  T. 


reversal  of  the  intermaxillary  elastics.  In  other  words, 
the  lower  canines  and  upper  molar  bands  were  utilized 
for  anchorage  of  the  rubbers. 


UNILATERAL  MESIOCLUSION 


281 


UNILATERAL  MESIOCLUSION 

As  its  name  implies,  this  type  of  malocclusion  presents 
mesial  closure  of  the  lower  arch  on  one  side  only,  the  relation 

Fio.  237 


Side  views,  before  and  after  treatment,  of  Case  U. 


being  neutral  upon  the  other.  Its  possible  combination 
with  a  unilateral  distoclusion — mesiodistoclusion — consti- 
tutes what  Angle  has  designated  as  Class  IV. 


282  TREATMENT  OF  MESIOCLUSION 

Unilateral  mesioclusions  are  extremely  rare,  and  their 
accompanying  complications  are  usually  less  pronounced 
than  in  the  bilateral  types.  The  etiology  is  even  more 
obscure,  though  the  treatment  is  decidedly  easier,  and 
rarely,  if  ever,  beyond  orthodontic  technique. 


Fig. 

238 

ss 

■ 

ss 

^ 

^H 

V^ 

^ 

^mjr^4 

^ 

ir*\^^l 

^^V^JH^^ 

ps 

^Fju..^^ 

^ 

^^A^^^l 

^^^yBSiiT^is - 

""  ^m 

k^^S 

^ 

ii 

^fl 

, 

1 

^"^1 

■^^^ 

■1 

i 

^ 

^^^^l^vV^^^lft^j^ 

'  iiiiiriM 

id 

"  bM 

^A^^JC^ 

^ 

I^B^Hi 

^^^yg 

1 

B^ 

3 

E 

n 

Occlusal  views,  before  and  after  treatment,  of  Case  U. 

Case  U. — A  boy,  aged  thirteen  years  (Figs.  237  and  238), 
with  negative  history  so  far  as  his  childhood  and  infancy  are 
concerned,  but  whose  father  has  a  malocclusion  of  identical 
form.  There  was  a  time  when  heredity  would  have  explained 
this  otherwise  unexplainable  phenomenon,  but  we  have 
learned  "not  to  spell  heredity  with  a  capital  'h.'  We  no 
longer  think  of  it  as  a  power  or  as  a  principle,  as  a  fate  or 
as  one  of  the  forces  of  nature."  Heredity  is  now  merely 
regarded  as  a  "convenient  term  to  express  the  genetic  rela- 


UNILATERAL  MESIOCLUSION  283 

tion  between  successive  generations,"  and  though  we  know 
infinitely  more  about  it  than  formerly,  we  have  not  yet 
succeeded  in  "measuring  and  weighing"  such  resemblances. 
Treatment  consisted  in  the  application  of  molar  anchor 
bands  and  alignment  wires  for  the  development  of  each 
arch  and  for  the  application  of  an  elastic  on  the  left  side 
as  in  Fig.  230.    The  upper  incisors  and  lower  canines  were 

Fig.  239 


Profile  of  Case  U  after  treatment.    (Compare  with  Fig.  67.) 

provided  with  plane  spurred  bands  for  the  more  secure 
attachment  of  their  ligatures  and  to  effect  rotation,  as  well 
as  labial  movement,  of  the  incisors. 

Maintenance  was  procured  by  an  appliance  like  that 
shown  in  Fig.  140  for  the  lower,  and  Fig.  179  (upper  diagram) 
for  the  upper.  The  improvement  in  the  facial  balance  can 
readily  be  noted  by  comparing  Fig.  239  with  Fig.  67, 


CHAPTER    XVIII 
TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS 

Though  the  achievements  of  orthodontics  are  truly 
wonderful,  it  is  well  that  we  recognize  its  limitations. 
Indeed,  its  methods  are  now  conceded  to  be  inadequate  for 
the  treatment  of  those  extreme  deformities  which  involve 
the  jaws,  and  to  which  the  reader's  attention  has  already 
been  called.  Fortunately,  the  skill  of  the  oral  surgeon 
frequently  offers  much  hope  to  those  afflicted  with  these 
very  distressing  disfigurements. 

In  view  of  the  fact  that  malocclusion  of  the  teeth  invari- 
ably accompanies  such  deformities  and  frequently  stands  in 
causal  relation  to  them  (thus  demanding  the  cooperation 
of  the  orthodontist),  it  seems  eminently  appropriate  to 
close  the  volume  with  a  brief  review  of  recent  advances  in 
this  field.  But  the  remedial  measures  about  to  be  described 
are  entirely  of  a  surgical  nature,  which  precludes  a  detailed 
discussion  of  their  technique.  Moreover,  the  author  con- 
fidently believes  that  no  definite  set  of  rules  can  be  laid 
down  for  guidance;  such  decision  must  rest  entirely  with  the 
surgeon.  However,  it  is  of  the  utmost  importance  that 
the  operator  carefully  consider  the  degree  of  deformity,  the 
anesthetic,  the  most  suitable  operation  for  a  given  case, 
the  best  method  for  postoperative  immobilization  of  the 
parts,  etc.  In  the  latter  phase,  the  orthodontist  can 
frequently  render  invaluable  service. 


TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS    285 

Oral  deformities  requiring  surgical  interference  were 
partly  enumerated  in  Chapter  V  as  follows: 

1.  Macrognathism,  overdevelopment  of  a  jaw. 

2.  Micrognathism,  arrested  development  of  a  jaw. 
These  may  be  more  specifically  designated  according  to 

their  location  by  the  addition  of  such  prefixes  as  man- 
dibular, maxillary,  and  bimaxillary,  and  by  combinations 
of  them.  To  this  list  (as  was  then  intimated)  must  be 
added  all  those  deformities  with  which  the  oral  surgeon 
has  to  deal.     The  latter  include: 

3.  Malposition  of  the  mandible. 

4.  Curvature  of  the  mandible. 

5.  Congenital  deformities,  such  as  clefts  of  the  palate, 
agnathism,  polygnathism,  etc. 

6.  Deformities  due  to  abnormal  extraneous  influences, 
such  as  blows,  burns,  fractures,  etc. 

7.  Deformities  resulting  from  disease — fibroma,  ankylosis, 
etc. 

The  most  pertinent  of  these  are  mandibular  macrogna- 
thism, micrognathism,  curvature,  and  malposition. 

The  historical  development  of  the  surgical  measures 
proposed  for  the  alleviation  of  these  deformities  was  briefly 
set  forth  by  Babcock^  in  a  paper  read  before  the  ninth 
annual  meeting  of  the  American  Society  of  Orthodontists 
held  in  Cleveland,  October,  1909,  from  which  the  following 
is  a  quotation : 

"As  to  the  history  of  what  has  been  done  in  these  opera- 
tions on  the  jaw,  a  brief  summary  may  be  permitted.  It 
is,  indeed,  surprising  how  few  operations  have  been  done. 
Starting  in  1S4S,  Dr.  S.  P.  Hullihen,^  of  Wheeling,  W.  Ya., 

'  Items  of  Interest,  June,  1910. 

2  Amer.  Jour.  Dental  Science,  1849,  p.  157. 


286     TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS 

did  the  pioneer  operation  for  an  elongated  jaw,  with  prog- 
nathism. We  should  name  him  with  a  great  deal  of  pride. 
He  had  to  do  with  a  patient  who  had  been  under  the  care 
of  some  of  the  best  surgeons  in  New  York,  only  to  meet  with 
failure  and  rather  an  increase  of  the  deformity.  Anesthesia 
was  not  generally  available,  the  germ  theory  and  antiseptics 
were  not  understood,  hemostatic  forceps  had  not  been 
invented,  and  much  in  the  way  of  surgical  technique  was 
yet  to  be  evolved,  but  this  man  had  the  hardihood  to  go 
ahead  and  do  a  series  of  very  extensive  operations  upon 
this  girl's  jaw  and  neck,  which  resulted  in  a  remarkable 
improvement,  if  not  a  complete  restoration.  The  case  was 
that  of  a  girl,  aged  twenty  years,  who  fifteen  years  before 
had  been  so  badly  burned  over  the  neck  that  the  jaw  was 
pulled  down  upon  the  chest,  and  there  had  been  produced 
an  elongation  of  the  mandible,  a  protrusion  of  the  lower 
incisors,  and  marked  e version  of  the  lower  lip. 

"With  a  small  saw  V-shaped  sections  were  resected  from 
each  side  of  the  jaw,  the  section  upon  the  left  side  including 
the  bicuspids.  The  V-shaped  sections  extended  two-thirds 
of  the  way  through  the  bone,  the  apices  being  below  (Fig. 
240).  From  the  apices  the  saw  was  turned  horizontally 
forward,  completing  the  section,  and  leaving  the  upper 
two-thirds  of  the  anterior  portion  of  the  mandible  attached 
to  the  soft  tissues  of  the  lip  only.  With  the  removal  of  the 
two  V-shaped  sections  of  bone  the  mobilized  portion  of  the 
jaw  could  be  pushed  back  into  place,  securing  an  occlusion 
of  the  incisors  (Fig.  241).  From  an  impression  taken  in  soft 
wax  a  silver  plate  was  then  struck  up,  which,  when  applied, 
held  the  section  of  the  jaw  in  proper  position.  Union  rapidly 
occurred,  and  Dr.  Hullihen  then  boldly  proceeded  to  correct 
the  defect  in  the  neck.    A  large  flap  of  skin  from  the  shoulder 


TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS     287 

and  arm  was  transplanted  to  the  neck,  enabling  the  head  to 
be  raised,  and  finally  by  two  further  operations  the  everted 
and  deformed  lower  lip  was  made  sightly  and  useful.  All 
of  these  operations  are  said  to  have  been  successful. 

Fig.  210 


Diagram  showing  type  of  deformity  in  HuIIihen'a  case,  the  dotted  lines  indicating 
the  lines  of  bone  section  and  the  triangular  segments  of  bone  to  be  removed.  (After 
Babcock.) 

Fig.  241 


Diagram  of  Hullihen's  case,  showing  his  method  of  correction.     (After  Babcock.) 

"Nearly  fifty  years  elapsed  before  bilateral  resection  of 
the  mandible  was  again  suggested.  In  1896  Dr.  R.  Otto- 
lengui/  in  discussing  the  subject,  suggested  the  feasibility 
of  such  a  procedure,  and  the  following  year  Dr.  James  W. 


»  Dental  Cosmos,  1897,  p.  143. 


288     TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS 

Whipple/  of  St.  Louisj  referred  to  Dr.  Edward  H.  Angle 
a  patient,  a  young  man,  with  a  progressive  type  of  prog- 
nathism. After  studying  this  patient.  Dr.  Angle  advised 
a  bilateral  resection  of  the  elongated  portions  of  the  jaw, 
between  the  first  molar  and  second  bicuspid  on  the  right  side, 
and  the  first  and  second  bicuspid  on  the  left  side,  the  sections 

Fig.  242 


Profiles  of  patient  before  and  after  double  resection  of  the  mandible.     (After  Ballin.) 


removed  differing  from  those  removed  by  Hullihen,  inas- 
much as  the  removed  segments  passed  through  the  entire 
depth  of  the  body  of  the  jaw.  This  operation  was  not 
performed  by  Dr.  Angle,  and  the  patient  finally  came  under 
the  care  of  a  surgeon.  Dr.  V.  P.  Blair,  who  resected  a  quadri- 

1  Dental  Cosmos,  189S,  p.  552. 


TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS     2S9 

lateral  section  from  each  side  of  the  jaw,  brought  the  teetli 
into  occlusion,  wired  them  in  place,  and  then  found  great 


Fia.  213 


Dental  models  before  and  after  operation;  the  lines  a  and  b  indicate  section 
removed.    (After  Ballin  ) 

19 


290     TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS 

difficulty  in  holding  all  the  fragments  of  the  jaw  in  occlusion. 
However,  after  nine  quite  troublesome  weeks  from  suppura- 
tion and  some  necrosis,  bony  union  and  a  very  creditable 

Fig.  244 


Typical  deformity,  with  dotted  lines  indicating  the  various  possible  sections. 
Section  made  from  b  to  d.     (After  Babcock.) 


result  were  obtained.^     The  publication  of  this  operation 
led  to  a  few  similar  operations,  which  in  some  cases  were 


I  Dental  Cosmos,  August,  1906. 


TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS     291 

followed  by  necrosis,  one  patient  in  New  Orleans  losing 
the  mandible  from  this  cause.    Although  this  operation  is 

Fig.  245 


Shows  possible  correction  after  sections  a-6  or  a-e.    (After  Babcock.) 


performed  through  incisions  from  below  the  jaw,  the  two 
compound  fractures  into  the  mouth  which  are  produced 
are  so  objectionable  that  a  preliminary  extraction  of  teeth, 


292     TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS 

to  be  followed  later  by  submucous  resection  of  the  bone, 
has  been  advised."^ 

The  operation  has  also  been  performed  by  von  Bergmann, 
Ballin^  (see  Figs.  242  and  243),  Babcock,  Cathcart,  and 
others.  The  difficulties  encountered  by  these  pioneers  has 
led  to  improvements  in  method.  Figs.  244,  245,  and  246 
show  a  skull  exhibiting  a  typical  deformity,  with  dotted 
lines  and  cuts  drawn  upon  the  ramus  to  indicate  several 

Fig.  246 


Correction  according  to  section  d-c.     (After  Babcock.) 

possible  ways  for  resection,  all  of  which  are  far  enough 
removed  from  the  body  of  the  bone  to  exclude  any  possible 
involvement  of  the  teeth.  From  these  it  can  readily  be 
seen  that  a  correction  of  the  deformities  above  referred  to 
are  quite  within  the  range  of  surgery,  and  that  they  offer 
the  only  feasible  plan  for  a  cure. 

Dr.  Blair^  reports  an  original  method  of  transplantation 


1  See  Blair,  Dental  Era,  April,  1907. 

2  Proc.  Amer.  Soc.  Orthodontists,  seventh  annual  report. 

3  Jour.  Amer.  Med.  Assoc,  July  17,  1909,  pp.  178  to  183, 


TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS     293 


FiQ.  247 


Profile  of  Dr.  Blair's  patient  prior  to  operation. 


Fig.  248 


Profile  of  Dr.  Blah's  patient  after  double  resection  and  transplantation  of 
costal  cartilage. 


294      TREATMENT  OF  MALFORMATIONS  OF  THE  JAWS 

of  the  curved  part  of  the  eighth  costal  cartilage,  with  its 
perichondrium,  to  the  mental  eminence  of  a  chin  in  a  patient 
suffering  from  mandibular  micrognathism.  This  was  for 
improvement  of  the  facial  lines,  which  a  bilateral  transverse 
section  of  the  rami  had  previously  failed  to  entirely  correct. 
The  vast  improvement  of  the  profile  is  clearly  shown  in 
Figs.  247  and  248. 

For  a  further  elucidation  of  the  subject  the  reader  is 
referred  to  the  original  monographs  enumerated  above. 


INDEX 


Abnormal  frenum  labium,  58,  61 
Accidents  causing  malocclusion,  74 
Acquired  malocclusions.     See  Eti- 
ology. 
Adenoids,  69 

Age  best  for  treatment,  138 
Alignment,  definition  of,  81 

variations  of,  105 

wire,  147, 159, 160, 161, 176,  224, 
225 
Aluminum   bronze  for  appliances, 

153 
Alveolar  process,  changes  in,  183 
Alveolitis  as  a  cause  of  malocclu- 
sion, 75 
Anchorage,  definition  of,  164 

extramaxillary,  170 

intermaxillary,  168 

intramaxillary,  167 

reciprocal,  166 

stationary,  165 
Angle's  appliances,  149 

classification  of  malocclusion,  88 

system,  149 
Anomalies  of  eruption,  84 

of  form,  58 

of  the  jaws,  84 

of  number,  56 

of  position,  63 

of '  structure,  84 

of  the  tongue,  65 
Appliances,  152 

Angle's,  149 

Case's,  163 

Farrar's,  148 

Fauchard's,  146 

Flagg's,  147 

metals  used  for,  152 


Appliances,  Patrick's,  148 

Schange's,  146 
Arch  form,  correction  of,  191 

maintenance  of,  187 
Artificial    nursing  as   a   cause   of 

malocclusion,  77 
Asymmetry  of  the  jaws,  63 


Bands,  anchor,  156 
application  of,  173 
attachments  to,  157 
introduction  of,  156 
kinds  of,  156 
uses  of,  156 
plain,  154 

application  of,  175 
introduction  of,  154,  155 
uses  of,  154 
retaining,  186 
Beauty  of  form,  definition  of,  121 
Buccoversion,  definition  of,  92 
treatment  of,  191 


Caries,  prevention  of,  36 
treatment  of,  38 

Case  contouring  appliance,  163 
modification  of,  197 

Cells  of  construction  and  destruc- 
tion, 183 

Cephalic  index,  99 

Civilization  as  a  cause  of  malocclu- 
sion, 78 

Cleansing  of  the  teeth,  36 

Cleft  palate  as  a  cause  of  malocclu- 
sion, 61 


296 


INDEX 


Deciduous  teeth,  premature  loss 
of,  66 
prolonged  retention  of,  67 
Dental  index,  99 
Dentition,  anomalies  of,  84 
Diagnosis,  definition  of,  83 

methods  of,  83 

nomenclature  of,  83 

rules  governing,  96 
Diseases  causing  malocclusion,  65 
Disharmonisms,  causes  of,  78 
Distoclusion,  definition  of,  89 

post-treatment  maintenance  of, 
189 

treatment  of,  245 
Distoversion,  definition  of,  92 

post-treatment  maintenance  of, 
186 

treatment  of,  198 
Disuse  of  teeth,  77 


E 


Early  treatment,  reasons  for,  130, 

137 
Elastic  rubber  bands,  163,  181 
Etiology  of  malocclusion,  52 

definition  of,  52 

extrinsic  factors,  66 

intrinsic  factors,  55 

unknown  factors,  77 
Examination  of  mouth,  32 
Extraction  of  teeth,  40 

evils  of,  41 

rules  governing,  41 


Facial  angle,  99 

deformities,  97 

diagnosis,  126 

harmony,  119,  122 

models,  48 

photographs,  49 
Farrar's  appliances,  148,  149 
Fauchard's  appliances,  146 
Flagg's  appliances,  147 
Forces,  anchorage  of,  164 
Frenum  labium,  abnormal,  58 
causes  of,  61 


G 


German  silver  for  appliances,  153 

texts.    See  Literature. 
Gilmer  plain  band,  155 
Gnathic  index,  99 
Gold  for  appliances,  152,  153 


Habits  causing  malocclusion,  71 
Health  as  a  factor  in  treatment, 

131 
Hereditary  transmission,  53,  282 
Hyperplastic  formation  of  connec- 
tive tissue,  77 


Impressions  for  models,  47 
Infraversion,  definition  of,  92 

treatment  of,  208 
Intermaxillary  anchorage,  168 
Intramaxillary  anchorage,  167 
Iridioplatinum  for  appliances,  152 


Jackscrew  for  reciprocal  anchor- 
age, 167 
for  torsoyersion,  205 
Jaws,  asymmetry  of,  63 
deformities  of,  87 

prevention  of,  85 
treatment  of  malformations  of, 
284 


Kingsley's  inclined  plane,  255 

Oral  Deformities,  21 
Knapp's  system,  149 


Labioversion,  definition  of,  92 
post-treatment  maintenance  of, 

187 
treatment  of,  192 

Lever  for  treatment  of  malocclu- 
sion, 163,  203 

Ligatures,  162 


INDEX 


29- 


Ligatures,  application  of,  181 
Linguoversion,  definition  of,  92 
post-treatment  maintenance  of, 

187 
treatment  of,  195 
Lip-biting  as  a  cause  of  malocclu- 
sion, 73 
Literature  of  orthodontics,  20 
American,  21 
English,  22 
French,  22 
German,  22 
Spanish,  22 

M 

Macrognathism  defined,  87 
Magill,  plain  band,  155 
Malalignment  defined,  81 
Malformation  of  jaws,  85 

treatment  of,  284 
Malocclusion  defined,  81 

differentiation  of,  85 
Malposition  defined,  81 

kinds  of,  92 

treatment  of,  191 
Malrelation  of  the  arches  defined, 
85 

treatment  of.     See  Distoclusion 
and  mesioclusion. 
Mechanical  formation  of  denture, 

77 
Megadont  defined,  101 
Mesioclusion  defined,  89 

treatment  of,  272 
Mesioversion  defined,  92 

treatment  of,  201 
Mesodont  defined,  101 
Mesognathous  defined,  99 
Microdont  defined,  101 
Micrognathism  defined,  87 
Models,  facial,  48 

plaster,  46 

uses  of,  47 
Mouth,  examination  of,  32 


N 


Nasal  obstruction,  67 

consequences   and   symptoms 
of,  69 


Neutroclusion  defined,  94 

treatment  of,  213 
Noble  metals  used  for  appUances, 

153 
Nomenclature  of  orthodontics,  19 
Non-occlusion  defined,  81 


O 


Obstetrical  deformity,  74 
Occipital  anchorage,  170 
Occlusion  defined,  81 

importance   of,    124,    138,    184, 
185 
Oral  hygiene,  37 
Orthodontics  defined,  17 

journals  of,  23 

literature  of,  20 

nomenclature  of,  19 

postgraduate  study  in,  26 

practice  of,  23 

societies  of,  23 

specialization  in,  24 

synonyms  of,  17 

technique  of,  26 
Osteoblasts,  184 


Pain,  relief  of,  35 

Palatal  index,  104 

Patrick's  appliances,  148 
system,  149 

Pericemental  affections,  75 

Pericementum,  fibers  and  functions 
of,  183 

Perversion  defined,  92 
treatment  of,  212 

Photographs,  49 

Plaster  models,  46 

Platinum,  uses  of,  152,  153 

Predisposition,  53,  54 

Premature  loss  of  teeth,  66 

Preparation   of  mouth   for   treat- 
ment, 31 

Profile,    abnormal    variations    of, 
108 
normal  variations  of,  99 

Prognathous  defined,  99 

Prognosis  defined,  130 


298 


INDEX 


Prolonged  retention  of  temporary 
teeth,  67 

Pulpless  teeth  requiring  move- 
ment, 39 


R 


Race    admixture   as   a   cause   of 

malocclusion,  78 
Radiographs,  50 
Reciprocal  anchorage,  166 
Records  of  treatment,  42 
Resorption  in  tooth  movement,  183 
Retaining    appliances,    186,    187, 

188,  189 
Retention  defined,  184 

of  arch  form,  187 
relation,  189 

of  tooth  position,  186 

time  required  for,  185 
Rotation    of    teeth.      See    Torso- 
version. 
Rubber  elastic  bands,  163,  181 

vulcanite  plates  forretention,  187 


S 


Schange's  appliance,  146 

Sex,  consideration  of,  in  treatment, 

131 
Skiagraphs.    See  Radiographs. 
Skull  cap,  163,  170,  171 
Supraversion  defined,  92 

treatment  of,  210 
Symphysis,  variations  of,  105 
Systems  of  treatment,  28 

Angle's,  149 

Case's,  149 

Farrar's,  149 

introduction  of,  148 

Jackson's,  149 

Knapp's,  149 

Lukens',  149 

Patrick's,  149 


Technique  of  orthodontics,  26 
Thumb-sucking  as  a  cause  of  mal- 
occlusion, 71 


Tissue  changes  caused  by  treat- 
ment, 183 
Tongue-sucking  as  a  cause  of  mal- 
occlusion, 73 
Tonsils,  hypertrophy  of,  69 
Torsoversion  defined,  92 

treatment  of,  203 
Transversion  defined,  92 

treatment  of,  212 
Traumatism,  74 
Treatment  of  buccoversion,  191 

of  distoclusion,  245 

of  distoversion,  198 

of  infraversion,  208 

of  labioversion,  191 

of  linguoversion,  195 

of  malformation  of  the  jaws,  284 

of  mesioclusion,  272 

of  mesioversion,  201 

of  neutroocclusion,  213 

of  perversion,  212 

records,  42 

of  supraversion,  210 

of  torsoversion,  203 

of  transversion,  212 
Tube  hooks,  162 
Tubes,  buccal,  174,  178 
Turbinates,  hypertrophy  of,  69 


Variations  of  alignment,  102 
of  the  facial  angle,  106 
of  the  head  form,  97 
of  lower  third  molars,  105 

Vulcanite  plates,  uses  of,  187 


W 

Wire    alignment,   147,   159,   160, 
161,  176,  224,  225 
ligatures,  162,  181 


X-RAYS.    See  Radiographs. 


COLUMBIA  UNIVERSITY 

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